Composition (PS-CA)

Element id

Composition

Short description

Canadian Patient Summary composition

Definition

Canadian 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.

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.

Data type

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.id

Short description

Logical id of this artifact

Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Mappings

rim: n/a

category

0..*

There are no (further) constraints on this element

Element id

Composition.category

Short description

Categorization of Composition

Definition

A 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.

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.

Data type

DocumentClassValueSet (example)

Binding

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

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

subject

SO Σ C

1..1

Element id

Composition.subject

Short description

Who and/or what the composition is about

Definition

Who 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 PS the subject is always the patient.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

0..1

There are no (further) constraints on this element

Element id

Composition.subject.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.subject.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

May 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.

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

reference

SO Σ C

1..1

Element id

Composition.subject.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

A 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.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, ref-1

Constraints

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

Mappings

rim: n/a
rim: N/A

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.subject.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The 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).

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.

Data type

uri

Binding

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

ResourceType (extensible)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Mappings

rim: n/a
rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

Composition.subject.identifier

Short description

Logical reference, when literal reference is not known

Definition

An 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.

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).

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

display

0..1

There are no (further) constraints on this element

Element id

Composition.subject.display

Short description

Text alternative for the resource

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Mappings

rim: n/a
rim: N/A

encounter

Σ C

0..1

Reference(Encounter)

Element id

Composition.encounter

Short description

Context of the Composition

Definition

Describes the clinical encounter or type of care this documentation is associated with.

Requirements

Provides context for the composition and supports searching.

Comments

While IPS-UV considers this a Must Support element, policy has not yet been developed in Canada confirming the expectations for when a patient summary is created (e.g., does it have to be created by a health professional or just validated, can it be automatically assembled, does it have to occur within an encounter, etc.). This relaxation does not exclude or prevent implementers from further defining how encounter is used in their implementation if their use case(s) rely on its presence.

Data type

Reference(Encounter)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

date

SO Σ

1..1

Element id

Composition.date

Short description

Composition editing time

Definition

The composition editing time, when the composition was last logically changed by the author.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

SO Σ C

1..*

Element id

Composition.author

Short description

Who and/or what authored the patient summary

Definition

Identifies who is responsible for the information in the patient summary, 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" PS Vs. an "automatically generated" PS.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

title

SO Σ

1..1

Element id

Composition.title

Short description

CA Patient Summary

Definition

Official human-readable label for the composition.

For this document should be "CA Patient Summary" or any equivalent translation

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

confidentiality

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.confidentiality

Short description

As defined by affinity domain

Definition

The code specifying the level of confidentiality of the Composition.

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.

Data type

v3.ConfidentialityClassification (required)

Binding

Codes specifying the level of confidentiality of the composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

attester

0..*

Element id

Composition.attester

Short description

Attests to accuracy of composition

Definition

A participant who has attested to the accuracy of the composition/document.

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

IPS-UV flags this as a Must Support element. It is not currently flagged as Must Support in PS-CA, as stakeholders have indicated the element may not be supported across workflows of Canadian jurisdictional implementers.

These challenges have been raised in IPS. Further assessment of jurisdictional use cases need to be explored by the Patient Summary Working Group before the constraint will be re-considered for inclusion

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.attester.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

May 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).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

mode

1..1

codeBinding

Element id

Composition.attester.mode

Short description

personal | professional | legal | official

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

While Composition.attester is not currently flagged as Must Support in PS-CA, Implementers who support attester are expected to support attester.mode, attester.time, and attester.party

Data type

CompositionAttestationMode (required)

Binding

The way in which a person authenticated a composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

time

0..1

Element id

Composition.attester.time

Short description

When the composition was attested

Definition

When the composition was attested by the party.

Requirements

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

Comments

While Composition.attester is not currently flagged as Must Support in PS-CA, Implementers who support attester are expected to support attester.mode, attester.time, and attester.party

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

party

SO C

0..1

Reference(OrganizationPSCA | PatientPSCA | PractitionerPSCA | PractitionerRolePSCA | RelatedPerson)

Element id

Composition.attester.party

Short description

Who attested the composition

Definition

Who attested the composition in the specified way.

Requirements

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

Comments

While Composition.attester is not currently flagged as Must Support in PS-CA, Implementers who support attester are expected to support attester.mode, attester.time, and attester.party

Data type

Reference(OrganizationPSCA | PatientPSCA | PractitionerPSCA | PractitionerRolePSCA | RelatedPerson)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

custodian

SO Σ C

0..1

Element id

Composition.custodian

Short description

Organization which maintains the composition

Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

relatesTo

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo

Short description

Relationships to other compositions/documents

Definition

Relationships that this composition has with other compositions or documents that already exist.

Comments

A document is a version specific composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

code

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.relatesTo.code

Short description

replaces | transforms | signs | appends

Definition

The type of relationship that this composition has with anther composition or document.

Comments

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

Data type

DocumentRelationshipType (required)

Binding

The type of relationship between documents.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

target[x]

1..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.target[x]

Short description

Target of the relationship

Definition

The target composition/document of this relationship.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

targetIdentifier

Data type

targetReference

Data type

event

0..*

Element id

Composition.event

Short description

The clinical service(s) being documented

Definition

IPS Note: The main activity being described by a PS is the provision of healthcare over a period of time. In the CDA representation of the PS 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 PS 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.

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.

Data type

Slicing

Unordered, Open, by code(Pattern)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

(All Slices)

The requirements in this element apply to all slices

0..1

There are no (further) constraints on this element

Element id

Composition.event.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.event.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

code

0..*

There are no (further) constraints on this element

Element id

Composition.event.code

Short description

Code(s) that apply to the event being documented

Definition

This 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.

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.

Data type

Binding

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

ActCode (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

period

Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.event.period

Short description

The period covered by the documentation

Definition

The 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.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

detail

Σ C

0..*

There are no (further) constraints on this element

Element id

Composition.event.detail

Short description

The event(s) being documented

Definition

The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

careProvisioningEvent

0..1

Element id

Composition.event:careProvisioningEvent

Short description

The care provisioning being documented

Definition

The provision of healthcare over a period of time this PS is documented.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.event:careProvisioningEvent.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event:careProvisioningEvent.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.event:careProvisioningEvent.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

code

SO Σ

1..*

CodeableConceptPattern

Element id

Composition.event:careProvisioningEvent.code

Short description

Code(s) that apply to the event being documented

Definition

Comments

While Composition.event:careProvisioningEvent slice is not currently flagged as Must Support in PS-CA, Implementers who support the slice are expected to support Composition.event:careProvisioningEvent.code and Composition.event:careProvisioningEvent.period

Data type

Binding

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

ActCode (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

period

SO Σ C

0..1

Element id

Composition.event:careProvisioningEvent.period

Short description

The period covered by the documentation

Definition

The 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.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

detail

Σ C

0..*

There are no (further) constraints on this element

Element id

Composition.event:careProvisioningEvent.detail

Short description

The event(s) being documented

Definition

The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

section

3..*

Element id

Composition.section

Short description

Sections composing the PS

Definition

The root of the sections that make up the PS-CA composition.

Data type

Slicing

Unordered, Open, by code(Pattern)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

(All Slices)

The requirements in this element apply to all slices

0..1

There are no (further) constraints on this element

Element id

Composition.section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

0..1

There are no (further) constraints on this element

Element id

Composition.section.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

code

1..1

Element id

Composition.section.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

The 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).

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section.text

Short description

Text summary of the section, for human interpretation

Definition

A 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.

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section.mode

Short description

working | snapshot | changes

Definition

How 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.

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

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.

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

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.

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionMedications

SO C

1..1

Element id

Composition.section:sectionMedications

Short description

PS-CA Medication Summary Section

Definition

The 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.

Because This section has been expanded in the PS-CA to model a medicationRequest profile in addition to medicationStatement profile initially included in IPS-UV.

Comments

IPS-UV requires a minimum cardinality of 1 on this section to ensure it is always populated with some kind of data - though has recently updated to allow for the provision of section.emptyReason. This constraint has been maintained in the PS-CA. Systems should utilize the section.entry with a resource when conveying that the subject has no known medications (e.g., clinical assertions that are captured alongside supportive data like date). The section.emptyReason is available to convey details for why the section entry is empty (e.g., data unavailable).

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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()
ips-comp-1: Either section.entry or emptyReason are present
(entry.reference.exists() or emptyReason.exists())

Mappings

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionMedications.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionMedications.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionMedications.title

Short description

Medication Summary section

Alternate names

header, label, caption

Definition

The 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

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionMedications.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionMedications.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

SO C

0..*

Element id

Composition.section:sectionMedications.entry

Short description

Medications relevant for the scope of the patient summary

Definition

This 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

Comments

This entry requires a medicationStatement or a medicationRequest.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

medicationStatement

0..*

Element id

Composition.section:sectionMedications.entry:medicationStatement

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

medicationRequest

0..*

Element id

Composition.section:sectionMedications.entry:medicationRequest

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

emptyReason

SO C

0..1

CodeableConceptBinding

Element id

Composition.section:sectionMedications.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionAllergies

SO C

1..1

Element id

Composition.section:sectionAllergies

Short description

PS-CA Allergies and Intolerances Section

Definition

This 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.

Comments

IPS-UV requires a minimum cardinality of 1 on this section to ensure it is always populated with some kind of data - though has recently updated to allow for the provision of section.emptyReason. This constraint has been maintained in the PS-CA. Systems should utilize the section.entry with a resource when conveying that the subject has no known allergies (e.g., clinical assertions that are captured alongside supportive data like date). The section.emptyReason is available to convey details for why the section entry is empty (e.g., data unavailable).

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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()
ips-comp-1: Either section.entry or emptyReason are present
(entry.reference.exists() or emptyReason.exists())

Mappings

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionAllergies.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionAllergies.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionAllergies.title

Short description

Allergies and Intolerances

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionAllergies.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionAllergies.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

S C

0..*

Element id

Composition.section:sectionAllergies.entry

Short description

Relevant allergies or intolerances (conditions) for that patient.

Definition

It 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.

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

allergyOrIntolerance

SO C

0..*

Element id

Composition.section:sectionAllergies.entry:allergyOrIntolerance

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

emptyReason

SO C

0..1

CodeableConceptBinding

Element id

Composition.section:sectionAllergies.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionProblems

SO C

1..1

Element id

Composition.section:sectionProblems

Short description

PS-CA Problems Section

Definition

The PS problem section lists and describes clinical problems or conditions currently being monitored for the patient.

Comments

IPS-UV requires a minimum cardinality of 1 on this section to ensure it is always populated with some kind of data - though has recently updated to allow for the provision of section.emptyReason. This constraint has been maintained in the PS-CA. Systems should utilize the section.entry with a resource when conveying that the subject has no known conditions (e.g., clinical assertions that are captured alongside supportive data like date). The section.emptyReason is available to convey details for why the section entry is empty (e.g., data unavailable).

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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()
ips-comp-1: Either section.entry or emptyReason are present
(entry.reference.exists() or emptyReason.exists())

Mappings

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionProblems.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionProblems.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionProblems.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionProblems.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionProblems.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

S C

0..*

Element id

Composition.section:sectionProblems.entry

Short description

Clinical problems or conditions currently being monitored for the patient.

Definition

It lists and describes clinical problems or conditions currently being monitored for the patient.

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

problem

SO C

0..*

Element id

Composition.section:sectionProblems.entry:problem

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

emptyReason

SO C

0..1

CodeableConceptBinding

Element id

Composition.section:sectionProblems.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionProceduresHx

0..1

Element id

Composition.section:sectionProceduresHx

Short description

PS-CA History of Procedures Section

Definition

The 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:

Invasive Diagnostic procedure: e.g., Cardiac catheterization; (the results of these procedure are documented in the results section)
Therapeutic procedure: e.g., dialysis;
Surgical procedure: e.g., appendectomy

Comments

IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error. Additionally vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionProceduresHx.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionProceduresHx.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionProceduresHx.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionProceduresHx.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionProceduresHx.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

S C

0..*

Element id

Composition.section:sectionProceduresHx.entry

Short description

Patient past procedures pertinent to the scope of this document.

Definition

It lists the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to:

Invasive Diagnostic procedure: e.g., Cardiac catheterization; (the results of these procedure are documented in the results section)
Therapeutic procedure: e.g., dialysis;
Surgical procedure: e.g., appendectomy.

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

procedure

SO C

0..*

Element id

Composition.section:sectionProceduresHx.entry:procedure

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionImmunizations

0..1

Element id

Composition.section:sectionImmunizations

Short description

PS-CA Immunizations Section

Definition

The 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.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionImmunizations.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionImmunizations.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionImmunizations.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionImmunizations.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionImmunizations.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

S C

0..*

Element id

Composition.section:sectionImmunizations.entry

Short description

Patient's immunization status and pertinent history.

Definition

It 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.

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

immunization

SO C

0..*

Element id

Composition.section:sectionImmunizations.entry:immunization

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionMedicalDevices

0..1

Element id

Composition.section:sectionMedicalDevices

Short description

PS-CA Medical Devices Section

Definition

The medical devices section contains narrative text and coded entries describing the patient history of medical device use.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionMedicalDevices.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionMedicalDevices.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionMedicalDevices.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionMedicalDevices.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionMedicalDevices.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

S C

0..*

Element id

Composition.section:sectionMedicalDevices.entry

Short description

Patient history of medical device use.

Definition

It 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.

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

deviceStatement

SO C

0..*

Element id

Composition.section:sectionMedicalDevices.entry:deviceStatement

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

Pending definition of a PS CA device use section profile in a future release of PS CA, implementors are encouraged to use the IPS device use section profile.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionResults

0..1

Element id

Composition.section:sectionResults

Short description

PS-CA Results Section

Definition

This 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.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionResults.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionResults.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionResults.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionResults.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionResults.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

SO C

0..*

Element id

Composition.section:sectionResults.entry

Short description

Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.

Definition

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.

Comments

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

Data type

Reference(ObservationResultsLaboratoryPathologyPSCA)

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

results-observation-laboratory-pathology

SO C

0..*

Element id

Composition.section:sectionResults.entry:results-observation-laboratory-pathology

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Reference(ObservationResultsLaboratoryPathologyPSCA)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:populate-if-known	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

results-observation-radiology

SO C

0..*

Element id

Composition.section:sectionResults.entry:results-observation-radiology

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:populate-if-known	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

results-diagnosticReport

SO C

0..*

Element id

Composition.section:sectionResults.entry:results-diagnosticReport

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

Pending definition of a PS CA diagnostic report profile in a future release of PS CA, implementors are encouraged to use the IPS diagnostic report profile.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:populate-if-known	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionVitalSigns

0..1

Element id

Composition.section:sectionVitalSigns

Short description

PS-CA Vital Signs Section

Definition

The 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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionVitalSigns.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionVitalSigns.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionVitalSigns.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionVitalSigns.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionVitalSigns.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

SO C

0..*

Element id

Composition.section:sectionVitalSigns.entry

Short description

Notable vital signs or physical findings.

Definition

Notable 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

Comments

IPS-UV and PS-CA point to the parent vital signs profile (http://hl7.org/fhir/StructureDefinition/vitalsigns) in the base FHIR specification, it is up to the jurisdictions to select and support the individual vital sign profiles. However, to support implementers in validation - the individual vital signs profiles have been included as individual slices below. The parent vital signs profile has been removed as a slice to prevent examples from matching multiple slices.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

BMI

0..*

Element id

Composition.section:sectionVitalSigns.entry:BMI

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

0..*

Element id

Composition.section:sectionVitalSigns.entry:BP

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

BodyHeight

0..*

Element id

Composition.section:sectionVitalSigns.entry:BodyHeight

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

BodyTemp

0..*

Element id

Composition.section:sectionVitalSigns.entry:BodyTemp

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

BodyWeight

0..*

Element id

Composition.section:sectionVitalSigns.entry:BodyWeight

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

HeadCircum

0..*

Element id

Composition.section:sectionVitalSigns.entry:HeadCircum

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

HeartRate

0..*

Element id

Composition.section:sectionVitalSigns.entry:HeartRate

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

OxygenSat

0..*

Element id

Composition.section:sectionVitalSigns.entry:OxygenSat

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

RespRate

0..*

Element id

Composition.section:sectionVitalSigns.entry:RespRate

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

VitalsPanel

0..*

Element id

Composition.section:sectionVitalSigns.entry:VitalsPanel

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionPastIllnessHx

0..1

Element id

Composition.section:sectionPastIllnessHx

Short description

PS-CA History of Past Illness Section

Definition

The History of Past Illness section contains a description of the conditions the patient suffered in the past.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionPastIllnessHx.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionPastIllnessHx.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionPastIllnessHx.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionPastIllnessHx.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionPastIllnessHx.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

S C

0..*

Element id

Composition.section:sectionPastIllnessHx.entry

Short description

Conditions the patient suffered in the past.

Definition

It contains a description of the conditions the patient suffered in the past.

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

pastProblem

SO C

0..*

Element id

Composition.section:sectionPastIllnessHx.entry:pastProblem

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionFunctionalStatus

0..1

Element id

Composition.section:sectionFunctionalStatus

Short description

PS-CA Functional Status

Definition

The 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.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionFunctionalStatus.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionFunctionalStatus.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionFunctionalStatus.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionFunctionalStatus.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionFunctionalStatus.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

S C

0..*

Element id

Composition.section:sectionFunctionalStatus.entry

Short description

Optional entry used to represent disabilities and functional assessments

Definition

It 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.

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

disability

SO C

0..*

Element id

Composition.section:sectionFunctionalStatus.entry:disability

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

functionalAssessment

SO C

0..*

Element id

Composition.section:sectionFunctionalStatus.entry:functionalAssessment

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionPlanOfCare

0..1

Element id

Composition.section:sectionPlanOfCare

Short description

PS-CA Plan of Care Section

Definition

The 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.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionPlanOfCare.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionPlanOfCare.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionPlanOfCare.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionPlanOfCare.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionPlanOfCare.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

S C

0..*

Element id

Composition.section:sectionPlanOfCare.entry

Short description

Optional entry used to represent structured care plans

Definition

Dynamic, 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]

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

carePlan

SO C

0..*

Element id

Composition.section:sectionPlanOfCare.entry:carePlan

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

documentReference

SO C

0..*

Element id

Composition.section:sectionPlanOfCare.entry:documentReference

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

immunizationRecommendation

0..*

Element id

Composition.section:sectionPlanOfCare.entry:immunizationRecommendation

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionSocialHistory

0..1

Element id

Composition.section:sectionSocialHistory

Short description

PS-CA Social History Section

Definition

The 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.)

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionSocialHistory.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionSocialHistory.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionSocialHistory.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionSocialHistory.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionSocialHistory.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

SO C

0..*

Element id

Composition.section:sectionSocialHistory.entry

Short description

Health related "lifestyle factors" or "lifestyle observations" (e.g., smoke habits; alcohol consumption; diets, risky habits.)

Definition

Description of the person’s Health related “lifestyle factors" or "lifestyle observations" (e.g., smoke habits; alcohol consumption; diets, risky habits.)

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

generalSocialHistory

0..*

Element id

Composition.section:sectionSocialHistory.entry:generalSocialHistory

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

smokingTobaccoUse

0..1

Element id

Composition.section:sectionSocialHistory.entry:smokingTobaccoUse

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

alcoholUse

0..1

Element id

Composition.section:sectionSocialHistory.entry:alcoholUse

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionPregnancyHx

0..1

Element id

Composition.section:sectionPregnancyHx

Short description

PS-CA History of Pregnancy Section

Definition

The 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.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionPregnancyHx.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionPregnancyHx.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionPregnancyHx.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionPregnancyHx.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionPregnancyHx.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

S C

0..*

Element id

Composition.section:sectionPregnancyHx.entry

Short description

Current pregnancy status and, optionally, information about the outcome of earlier pregnancies.

Definition

It contains information about whether the patient is currently pregnant or not. It may contain addition summarizing information about the outcome of earlier pregnancies.

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

pregnancyStatus

SO C

0..*

Element id

Composition.section:sectionPregnancyHx.entry:pregnancyStatus

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

Pending definition of a PS CA pregnancy status observation profile in a future release of PS CA, implementors are encouraged to use the IPS pregnancy status observation profile.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

pregnancyOutcome

SO C

0..*

Element id

Composition.section:sectionPregnancyHx.entry:pregnancyOutcome

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

Pending definition of a PS CA pregnancy outcome observation profile in a future release of PS CA, implementors are encouraged to use the IPS pregnancy outcome observation profile.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionAdvanceDirectives

0..1

Element id

Composition.section:sectionAdvanceDirectives

Short description

PS-CA Advance Directives Section

Definition

The advance directives section contains a narrative description of patient's advance directive.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionAdvanceDirectives.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionAdvanceDirectives.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionAdvanceDirectives.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionAdvanceDirectives.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionAdvanceDirectives.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

SO C

0..*

Element id

Composition.section:sectionAdvanceDirectives.entry

Short description

Narrative description of the patient's advance directive.

Definition

Contains a narrative description or a Consent entry with information about the patient's advance directive.

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

advanceDirectivesConsent

0..*

Element id

Composition.section:sectionAdvanceDirectives.entry:advanceDirectivesConsent

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

advanceDirectivesDocumentReference

0..*

Element id

Composition.section:sectionAdvanceDirectives.entry:advanceDirectivesDocumentReference

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionFamilyHistory

0..1

Element id

Composition.section:sectionFamilyHistory

Short description

PS-CA Family History Section

Definition

The family history section contains a description of the patient's family history.

Comments

This is a new section being introduced by the PS-CA specification at the request of jurisdictions.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionFamilyHistory.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionFamilyHistory.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionFamilyHistory.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionFamilyHistory.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10157-6"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionFamilyHistory.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

S C

0..*

Element id

Composition.section:sectionFamilyHistory.entry

Short description

Narrative description of the patient's family history.

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

FamilyMemberHistory

SO C

0..*

Element id

Composition.section:sectionFamilyHistory.entry:FamilyMemberHistory

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..0

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

sectionPatientStory

0..1

Element id

Composition.section:sectionPatientStory

Short description

PS-CA Patient Story Section

Definition

The section contains narrative text along with optional resources that express what matters to a patient. This may include needs, strengths, values, concerns and preferences to others providing support and care. The patient’s story, provided here, may be told by the patient or by a proxy.

Comments

This is a new section being introduced by the PS-CA specification at the request of jurisdictions. While the Patient Story section is relatively unconstrained at this time, information that is better suited to another section should not be included in the Patient Story. For example, DNR orders should be placed in the Advanced Directives section.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionPatientStory.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Composition.section:sectionPatientStory.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

section-note

0..*

Element id

Composition.section:sectionPatientStory.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Alternate names

extensions, user content

Definition

Additional notes that apply to the section (but not to specific resource).

Comments

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

Data type

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPatientStory.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

title

1..1

Element id

Composition.section:sectionPatientStory.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The 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.

Requirements

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

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

1..1

Element id

Composition.section:sectionPatientStory.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "81338-6"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPatientStory.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionPatientStory.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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)

text

SO C

1..1

Element id

Composition.section:sectionPatientStory.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionPatientStory.mode

Short description

working | snapshot | changes

Definition

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.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionPatientStory.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

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

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPatientStory.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

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

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:sectionPatientStory.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

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

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:sectionPatientStory.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

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

CompositionPSCA (Composition)

There are no (further) constraints on this element

Element id

Composition

Short description

Canadian Patient Summary composition

Definition

Data type

text

There are no (further) constraints on this element

Element id

Composition.text

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Obligations

Code	Actor
SHALL:populate-if-known	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

identifier

There are no (further) constraints on this element

Element id

Composition.identifier

Obligations

Code	Actor
SHALL:populate-if-known	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

status

There are no (further) constraints on this element

Element id

Composition.status

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

type

Pattern

There are no (further) constraints on this element

Element id

Composition.type

Short description

Kind of composition ("Patient Summary")

Definition

Specifies that this composition refers to a Patient Summary (Loinc "60591-5")

Pattern

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

subject

1..

There are no (further) constraints on this element

Element id

Composition.subject

Definition

Data type

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

reference

1..

There are no (further) constraints on this element

Element id

Composition.subject.reference

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

encounter

There are no (further) constraints on this element

Element id

Composition.encounter

Comments

date

There are no (further) constraints on this element

Element id

Composition.date

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

author

There are no (further) constraints on this element

Element id

Composition.author

Short description

Who and/or what authored the patient summary

Definition

Identifies who is responsible for the information in the patient summary, 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" PS Vs. an "automatically generated" PS.

Data type

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

title

There are no (further) constraints on this element

Element id

Composition.title

Short description

CA Patient Summary

Definition

Official human-readable label for the composition.

For this document should be "CA Patient Summary" or any equivalent translation

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

attester

There are no (further) constraints on this element

Element id

Composition.attester

Comments

mode

There are no (further) constraints on this element

Element id

Composition.attester.mode

Comments

While Composition.attester is not currently flagged as Must Support in PS-CA, Implementers who support attester are expected to support attester.mode, attester.time, and attester.party

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

time

There are no (further) constraints on this element

Element id

Composition.attester.time

Comments

While Composition.attester is not currently flagged as Must Support in PS-CA, Implementers who support attester are expected to support attester.mode, attester.time, and attester.party

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

party

Reference(OrganizationPSCA | PatientPSCA | PractitionerPSCA | PractitionerRolePSCA | RelatedPerson)

There are no (further) constraints on this element

Element id

Composition.attester.party

Comments

While Composition.attester is not currently flagged as Must Support in PS-CA, Implementers who support attester are expected to support attester.mode, attester.time, and attester.party

Data type

Reference(OrganizationPSCA | PatientPSCA | PractitionerPSCA | PractitionerRolePSCA | RelatedPerson)

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

custodian

There are no (further) constraints on this element

Element id

Composition.custodian

Data type

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

relatesTo

There are no (further) constraints on this element

target[x]

There are no (further) constraints on this element

Element id

Composition.relatesTo.target[x]

targetIdentifier

There are no (further) constraints on this element

Data type

targetReference

There are no (further) constraints on this element

Data type

event

There are no (further) constraints on this element

Element id

Composition.event

Definition

Slicing

Unordered, Open, by code(Pattern)

careProvisioningEvent

0..1

There are no (further) constraints on this element

Element id

Composition.event:careProvisioningEvent

Short description

The care provisioning being documented

Definition

The provision of healthcare over a period of time this PS is documented.

code

1..

Pattern

There are no (further) constraints on this element

Element id

Composition.event:careProvisioningEvent.code

Comments

Pattern

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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

period

There are no (further) constraints on this element

Element id

Composition.event:careProvisioningEvent.period

Comments

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

3..

There are no (further) constraints on this element

Element id

Composition.section

Short description

Sections composing the PS

Definition

The root of the sections that make up the PS-CA composition.

Slicing

Unordered, Open, by code(Pattern)

(All Slices)

The requirements in this element apply to all slices

extension

There are no (further) constraints on this element

Element id

Composition.section.extension

Slicing

Unordered, Open, by url(Value)

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

code

1..

There are no (further) constraints on this element

Element id

Composition.section.code

Data type

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

text

1..

There are no (further) constraints on this element

Element id

Composition.section.text

Comments

PS-CA is following IPS guidance regarding text and section.text. It is recommended that documents do not duplicate the content in Composition.section.text with content in Composition.text.

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

sectionMedications

SO C

1..1

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications

Short description

PS-CA Medication Summary Section

Definition

The 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.

Because This section has been expanded in the PS-CA to model a medicationRequest profile in addition to medicationStatement profile initially included in IPS-UV.

Comments

Constraints

ips-comp-1: Either section.entry or emptyReason are present
(entry.reference.exists() or emptyReason.exists())

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.title

Short description

Medication Summary section

Definition

The 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

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.entry

Short description

Medications relevant for the scope of the patient summary

Definition

This 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

Comments

This entry requires a medicationStatement or a medicationRequest.

Slicing

Unordered, Open, by resolve()(Profile)

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

medicationStatement

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.entry:medicationStatement

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Data type

medicationRequest

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.entry:medicationRequest

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Data type

emptyReason

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.emptyReason

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionMedications.section

sectionAllergies

SO C

1..1

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies

Short description

PS-CA Allergies and Intolerances Section

Definition

Comments

IPS-UV requires a minimum cardinality of 1 on this section to ensure it is always populated with some kind of data - though has recently updated to allow for the provision of section.emptyReason. This constraint has been maintained in the PS-CA. Systems should utilize the section.entry with a resource when conveying that the subject has no known allergies (e.g., clinical assertions that are captured alongside supportive data like date). The section.emptyReason is available to convey details for why the section entry is empty (e.g., data unavailable).

Constraints

ips-comp-1: Either section.entry or emptyReason are present
(entry.reference.exists() or emptyReason.exists())

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.title

Short description

Allergies and Intolerances

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.entry

Short description

Relevant allergies or intolerances (conditions) for that patient.

Definition

Slicing

Unordered, Open, by resolve()(Profile)

allergyOrIntolerance

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.entry:allergyOrIntolerance

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Data type

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

emptyReason

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.emptyReason

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionAllergies.section

sectionProblems

SO C

1..1

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems

Short description

PS-CA Problems Section

Definition

The PS problem section lists and describes clinical problems or conditions currently being monitored for the patient.

Comments

IPS-UV requires a minimum cardinality of 1 on this section to ensure it is always populated with some kind of data - though has recently updated to allow for the provision of section.emptyReason. This constraint has been maintained in the PS-CA. Systems should utilize the section.entry with a resource when conveying that the subject has no known conditions (e.g., clinical assertions that are captured alongside supportive data like date). The section.emptyReason is available to convey details for why the section entry is empty (e.g., data unavailable).

Constraints

ips-comp-1: Either section.entry or emptyReason are present
(entry.reference.exists() or emptyReason.exists())

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.title

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.entry

Short description

Clinical problems or conditions currently being monitored for the patient.

Definition

It lists and describes clinical problems or conditions currently being monitored for the patient.

Slicing

Unordered, Open, by resolve()(Profile)

problem

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.entry:problem

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Data type

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

emptyReason

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.emptyReason

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionProblems.section

sectionProceduresHx

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx

Short description

PS-CA History of Procedures Section

Definition

The 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:

Invasive Diagnostic procedure: e.g., Cardiac catheterization; (the results of these procedure are documented in the results section)
Therapeutic procedure: e.g., dialysis;
Surgical procedure: e.g., appendectomy

Comments

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.title

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.entry

Short description

Patient past procedures pertinent to the scope of this document.

Definition

It lists the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to:

Invasive Diagnostic procedure: e.g., Cardiac catheterization; (the results of these procedure are documented in the results section)
Therapeutic procedure: e.g., dialysis;
Surgical procedure: e.g., appendectomy.

Slicing

Unordered, Open, by resolve()(Profile)

procedure

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.entry:procedure

Data type

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionProceduresHx.section

sectionImmunizations

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations

Short description

PS-CA Immunizations Section

Definition

Comments

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.title

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.entry

Short description

Patient's immunization status and pertinent history.

Definition

Slicing

Unordered, Open, by resolve()(Profile)

immunization

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.entry:immunization

Data type

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionImmunizations.section

sectionMedicalDevices

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices

Short description

PS-CA Medical Devices Section

Definition

The medical devices section contains narrative text and coded entries describing the patient history of medical device use.

Comments

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.title

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.entry

Short description

Patient history of medical device use.

Definition

Slicing

Unordered, Open, by resolve()(Profile)

deviceStatement

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.entry:deviceStatement

Comments

Pending definition of a PS CA device use section profile in a future release of PS CA, implementors are encouraged to use the IPS device use section profile.

Data type

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionMedicalDevices.section

sectionResults

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionResults

Short description

PS-CA Results Section

Definition

Comments

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

Reference(ObservationResultsLaboratoryPathologyPSCA)

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.title

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.entry

Short description

Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.

Definition

Slicing

Unordered, Open, by resolve()(Profile)

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

results-observation-laboratory-pathology

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.entry:results-observation-laboratory-pathology

Data type

Reference(ObservationResultsLaboratoryPathologyPSCA)

Obligations

Code	Actor
SHALL:populate-if-known	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

results-observation-radiology

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.entry:results-observation-radiology

Data type

Obligations

Code	Actor
SHALL:populate-if-known	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

results-diagnosticReport

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.entry:results-diagnosticReport

Comments

Pending definition of a PS CA diagnostic report profile in a future release of PS CA, implementors are encouraged to use the IPS diagnostic report profile.

Data type

Obligations

Code	Actor
SHALL:populate-if-known	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionResults.section

sectionVitalSigns

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns

Short description

PS-CA Vital Signs Section

Definition

Comments

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.title

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.entry

Short description

Notable vital signs or physical findings.

Definition

Comments

Slicing

Unordered, Open, by resolve()(Profile)

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

BMI

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.entry:BMI

Data type

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.entry:BP

Data type

BodyHeight

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.entry:BodyHeight

Data type

BodyTemp

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.entry:BodyTemp

Data type

BodyWeight

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.entry:BodyWeight

Data type

HeadCircum

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.entry:HeadCircum

Data type

HeartRate

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.entry:HeartRate

Data type

OxygenSat

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.entry:OxygenSat

Data type

RespRate

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.entry:RespRate

Data type

VitalsPanel

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.entry:VitalsPanel

Data type

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionVitalSigns.section

sectionPastIllnessHx

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx

Short description

PS-CA History of Past Illness Section

Definition

The History of Past Illness section contains a description of the conditions the patient suffered in the past.

Comments

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.title

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.entry

Short description

Conditions the patient suffered in the past.

Definition

It contains a description of the conditions the patient suffered in the past.

Slicing

Unordered, Open, by resolve()(Profile)

pastProblem

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.entry:pastProblem

Data type

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionPastIllnessHx.section

sectionFunctionalStatus

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus

Short description

PS-CA Functional Status

Definition

Comments

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.title

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.entry

Short description

Optional entry used to represent disabilities and functional assessments

Definition

Slicing

Unordered, Open, by resolve()(Profile)

disability

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.entry:disability

Data type

Obligations

Code	Actor
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

functionalAssessment

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.entry:functionalAssessment

Data type

Obligations

Code	Actor
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionFunctionalStatus.section

sectionPlanOfCare

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare

Short description

PS-CA Plan of Care Section

Definition

Comments

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.title

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.entry

Short description

Optional entry used to represent structured care plans

Definition

Slicing

Unordered, Open, by resolve()(Profile)

carePlan

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.entry:carePlan

Data type

Obligations

Code	Actor
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

documentReference

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.entry:documentReference

Data type

Obligations

Code	Actor
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

immunizationRecommendation

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.entry:immunizationRecommendation

Data type

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionPlanOfCare.section

sectionSocialHistory

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory

Short description

PS-CA Social History Section

Definition

The 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.)

Comments

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.title

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.entry

Short description

Health related "lifestyle factors" or "lifestyle observations" (e.g., smoke habits; alcohol consumption; diets, risky habits.)

Definition

Description of the person’s Health related “lifestyle factors" or "lifestyle observations" (e.g., smoke habits; alcohol consumption; diets, risky habits.)

Slicing

Unordered, Open, by resolve()(Profile)

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

generalSocialHistory

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.entry:generalSocialHistory

Data type

smokingTobaccoUse

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.entry:smokingTobaccoUse

Data type

alcoholUse

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.entry:alcoholUse

Data type

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionSocialHistory.section

sectionPregnancyHx

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx

Short description

PS-CA History of Pregnancy Section

Definition

Comments

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.title

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.entry

Short description

Current pregnancy status and, optionally, information about the outcome of earlier pregnancies.

Definition

It contains information about whether the patient is currently pregnant or not. It may contain addition summarizing information about the outcome of earlier pregnancies.

Slicing

Unordered, Open, by resolve()(Profile)

pregnancyStatus

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.entry:pregnancyStatus

Comments

Pending definition of a PS CA pregnancy status observation profile in a future release of PS CA, implementors are encouraged to use the IPS pregnancy status observation profile.

Data type

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

pregnancyOutcome

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.entry:pregnancyOutcome

Comments

Pending definition of a PS CA pregnancy outcome observation profile in a future release of PS CA, implementors are encouraged to use the IPS pregnancy outcome observation profile.

Data type

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionPregnancyHx.section

sectionAdvanceDirectives

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives

Short description

PS-CA Advance Directives Section

Definition

The advance directives section contains a narrative description of patient's advance directive.

Comments

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.title

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.code

Pattern

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

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.entry

Short description

Narrative description of the patient's advance directive.

Definition

Contains a narrative description or a Consent entry with information about the patient's advance directive.

Slicing

Unordered, Open, by resolve()(Profile)

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

advanceDirectivesConsent

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.entry:advanceDirectivesConsent

Data type

advanceDirectivesDocumentReference

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.entry:advanceDirectivesDocumentReference

Data type

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionAdvanceDirectives.section

sectionFamilyHistory

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory

Short description

PS-CA Family History Section

Definition

The family history section contains a description of the patient's family history.

Comments

This is a new section being introduced by the PS-CA specification at the request of jurisdictions.

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL

title

1..

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.title

Obligations

Code	Actor
SHALL:populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHALL:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:display	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

code

Pattern

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.code

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10157-6"
    }
  ]
}

entry

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.entry

Short description

Narrative description of the patient's family history.

Slicing

Unordered, Open, by resolve()(Profile)

FamilyMemberHistory

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.entry:FamilyMemberHistory

Data type

Obligations

Code	Actor
SHALL:able-to-populate	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/producer
SHALL:no-error	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer
SHOULD:handle	http://fhir.infoway-inforoute.ca/io/psca/ActorDefinition/consumer

section

..0

There are no (further) constraints on this element

Element id

Composition.section:sectionFamilyHistory.section

sectionPatientStory

0..1

There are no (further) constraints on this element

Element id

Composition.section:sectionPatientStory

Short description

PS-CA Patient Story Section

Definition

Comments

section-note

0..*

There are no (further) constraints on this element

Element id

Composition.section:sectionPatientStory.extension:section-note

Short description

Additional notes that apply to the section (but not to specific resource).

Definition

Additional notes that apply to the section (but not to specific resource).

Data type

Extension URL