Profile: CareConnect-GPC-Composition-1
| CareConnect-GPC-Composition-1 (Composition) | C | Composition | |
| id | Σ | 1..1 | id |
| meta | Σ | 0..1 | Meta |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| versionId | Σ | 0..1 | id |
| lastUpdated | Σ | 0..1 | instant |
| profile | Σ | 1..* | uri |
| security | Σ | 0..* | CodingBinding |
| tag | Σ | 0..* | Coding |
| implicitRules | Σ ?! | 0..1 | uri |
| language | 0..1 | codeBinding | |
| text | C | 0..1 | Narrative |
| contained | 0..* | Resource | |
| extension | C | 0..* | Extension |
| careSettingTypeExtension | C | 0..1 | Extension(CodeableConcept) |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| url | 1..1 | uriFixed Value | |
| valueCodeableConcept | 1..1 | CodeableConceptBinding | |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| coding | Σ | 1..1 | Coding |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| system | Σ | 1..1 | uriFixed Value |
| version | Σ | 0..0 | string |
| code | Σ | 1..1 | code |
| display | Σ | 1..1 | string |
| userSelected | Σ | 0..0 | boolean |
| text | Σ | 0..0 | string |
| modifierExtension | ?! C | 0..* | Extension |
| identifier | Σ | 0..1 | Identifier |
| (All Slices) | |||
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| use | Σ ?! | 0..1 | codeBinding |
| type | Σ | 0..1 | CodeableConceptBinding |
| system | Σ | 1..1 | uri |
| value | Σ | 1..1 | string |
| period | Σ C | 0..1 | Period |
| assigner | Σ C | 0..1 | Reference(CareConnect-Organization-1) |
| crossCareSettingIdentifier | Σ | 1..1 | Identifier |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| use | Σ ?! | 0..1 | codeBinding |
| type | Σ | 0..1 | CodeableConceptBinding |
| system | Σ | 1..1 | uriFixed Value |
| value | Σ | 1..1 | string |
| period | Σ C | 0..1 | Period |
| assigner | Σ C | 0..1 | Reference(CareConnect-Organization-1 | CareConnect-GPC-Organization-1) |
| identifier | Σ | 0..1 | Identifier |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| use | Σ ?! | 0..1 | codeBinding |
| type | Σ | 0..1 | CodeableConceptBinding |
| system | Σ | 1..1 | uri |
| value | Σ | 1..1 | string |
| period | Σ C | 0..1 | Period |
| assigner | Σ C | 0..1 | Reference(CareConnect-Organization-1 | CareConnect-GPC-Organization-1) |
| status | Σ ?! | 1..1 | codeBindingFixed Value |
| type | Σ | 1..1 | CodeableConceptBinding |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| coding | Σ | 1..* | Coding |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| system | Σ | 1..1 | uriFixed Value |
| version | Σ | 0..0 | string |
| code | Σ | 1..1 | codeFixed Value |
| display | Σ | 1..1 | stringFixed Value |
| userSelected | Σ | 0..0 | boolean |
| text | Σ | 0..1 | string |
| class | Σ | 0..1 | CodeableConcept |
| subject | Σ C | 1..1 | Reference(CareConnect-GPC-Patient-1) |
| encounter | Σ C | 1..1 | Reference(CareConnect-GPC-Encounter-1) |
| date | Σ | 1..1 | dateTime |
| author | Σ C | 1..* | Reference(Device | RelatedPerson | CareConnect-Patient-1 | CareConnect-GPC-Practitioner-1) |
| title | Σ | 1..1 | string |
| confidentiality | Σ ?! | 0..0 | codeBinding |
| attester | Σ | 0..0 | BackboneElement |
| custodian | Σ C | 0..0 | Reference(CareConnect-Organization-1) |
| relatesTo | Σ | 0..0 | BackboneElement |
| event | Σ | 0..0 | BackboneElement |
| section | C | 1..* | BackboneElement |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| problemReference | C | 0..* | Extension |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| url | 1..1 | uriFixed Value | |
| value[x] | 0..1 | ||
| valueAddress | Address | ||
| valueAge | Age | ||
| valueAnnotation | Annotation | ||
| valueAttachment | Attachment | ||
| valueBase64Binary | base64Binary | ||
| valueBoolean | boolean | ||
| valueCode | code | ||
| valueCodeableConcept | CodeableConcept | ||
| valueCoding | Coding | ||
| valueContactPoint | ContactPoint | ||
| valueCount | Count | ||
| valueDate | date | ||
| valueDateTime | dateTime | ||
| valueDecimal | decimal | ||
| valueDistance | Distance | ||
| valueDuration | Duration | ||
| valueHumanName | HumanName | ||
| valueId | id | ||
| valueIdentifier | Identifier | ||
| valueInstant | instant | ||
| valueInteger | integer | ||
| valueMarkdown | markdown | ||
| valueMeta | Meta | ||
| valueMoney | Money | ||
| valueOid | oid | ||
| valuePeriod | Period | ||
| valuePositiveInt | positiveInt | ||
| valueQuantity | Quantity | ||
| valueRange | Range | ||
| valueRatio | Ratio | ||
| valueReference | Reference | ||
| valueSampledData | SampledData | ||
| valueSignature | Signature | ||
| valueString | string | ||
| valueTime | time | ||
| valueTiming | Timing | ||
| valueUnsignedInt | unsignedInt | ||
| valueUri | uri | ||
| modifierExtension | Σ ?! C | 0..* | Extension |
| title | 0..1 | string | |
| code | 1..1 | CodeableConceptBinding | |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| coding | Σ | 1..* | Coding |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| system | Σ | 1..1 | uriFixed Value |
| version | Σ | 0..0 | string |
| code | Σ | 1..1 | codeFixed Value |
| display | Σ | 1..1 | stringFixed Value |
| userSelected | Σ | 0..0 | boolean |
| text | Σ | 0..1 | string |
| text | C | 0..1 | Narrative |
| mode | Σ ?! | 1..1 | codeBindingFixed Value |
| orderedBy | 1..1 | CodeableConceptBinding | |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| coding | Σ | 0..* | Coding |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| system | Σ | 1..1 | uriFixed Value |
| version | Σ | 0..0 | string |
| code | Σ | 0..1 | code |
| display | Σ | 0..1 | string |
| userSelected | Σ | 0..0 | boolean |
| text | Σ | 0..1 | string |
| entry | C | 0..* | Reference(ReferralRequest | CareConnect-GPC-AllergyIntolerance-1 | CareConnect-GPC-MedicationRequest-1 | CareConnect-GPC-Observation-1) |
| emptyReason | C | 0..0 | CodeableConceptBinding |
| section | C | 0..* | see (section) |
| Composition | |||
| Short | A set of resources composed into a single coherent clinical statement with clinical attestation | ||
| Definition | 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. | ||
| Cardinality | 0..* | ||
| 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. | ||
| Constraints |
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| Composition.id | |||
| Short | 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. | ||
| Cardinality | 1..1 | ||
| Type | id | ||
| Summary | True | ||
| 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. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Composition.meta | |||
| Short | Metadata about the resource | ||
| Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource. | ||
| Cardinality | 0..1 | ||
| Type | Meta | ||
| Summary | True | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Composition.meta.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Composition.meta.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
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| Composition.meta.versionId | |||
| Short | Version specific identifier | ||
| Definition | The version specific identifier, as it appears in the version portion of the URL. This values changes when the resource is created, updated, or deleted. | ||
| Cardinality | 0..1 | ||
| Type | id | ||
| Summary | True | ||
| Comments | The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Composition.meta.lastUpdated | |||
| Short | When the resource version last changed | ||
| Definition | When the resource last changed - e.g. when the version changed. | ||
| Cardinality | 0..1 | ||
| Type | instant | ||
| Summary | True | ||
| Comments | This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
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| Composition.meta.profile | |||
| Short | Profiles this resource claims to conform to | ||
| Definition | A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. | ||
| Cardinality | 1..* | ||
| Type | uri | ||
| Summary | True | ||
| Comments | It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
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| Composition.meta.security | |||
| Short | Security Labels applied to this resource | ||
| Definition | Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. | ||
| Cardinality | 0..* | ||
| Type | Coding | ||
| Binding | Security Labels from the Healthcare Privacy and Security Classification System. | ||
| Summary | True | ||
| Comments | The security labels can be updated without changing the stated version of the resource The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
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| Composition.meta.tag | |||
| Short | Tags applied to this resource | ||
| Definition | Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource. | ||
| Cardinality | 0..* | ||
| Type | Coding | ||
| Binding | Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||
| Summary | True | ||
| Comments | The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
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| Composition.implicitRules | |||
| Short | A set of rules under which this content was created | ||
| Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. | ||
| Cardinality | 0..1 | ||
| Type | uri | ||
| Modifier | True | ||
| Summary | True | ||
| Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Composition.language | |||
| Short | Language of the resource content | ||
| Definition | The base language in which the resource is written. | ||
| Cardinality | 0..1 | ||
| Type | code | ||
| Binding | A human language. Binding extensions
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| Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Composition.text | |||
| Short | Text summary of the resource, for human interpretation | ||
| Definition | A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | ||
| Cardinality | 0..1 | ||
| Type | Narrative | ||
| Alias | narrative, html, xhtml, display | ||
| Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1, dom-1 | ||
| Constraints |
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| Composition.contained | |||
| Short | Contained, inline Resources | ||
| Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | ||
| Cardinality | 0..* | ||
| Type | Resource | ||
| Alias | inline resources, anonymous resources, contained resources | ||
| Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. | ||
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| Composition.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 | ||
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| Composition.extension:careSettingTypeExtension | |||
| Short | An extension to carry the Care setting type of the document | ||
| Definition | Optional Extension Element - found in all resources. | ||
| Cardinality | 0..1 | ||
| Type | Extension(CodeableConcept) | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Composition.extension:careSettingTypeExtension.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
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| Composition.extension:careSettingTypeExtension.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
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| Composition.extension:careSettingTypeExtension.url | |||
| Short | identifies the meaning of the extension | ||
| Definition | Source of the definition for the extension code - a logical name or a URL. | ||
| Cardinality | 1..1 | ||
| Type | uri | ||
| Comments | The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Fixed Value | https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-CareSettingType-1 | ||
| Mappings |
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| Composition.extension:careSettingTypeExtension.value[x]:valueCodeableConcept | |||
| Short | Value of extension | ||
| Definition | Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list). | ||
| Cardinality | 1..1 | ||
| Type | CodeableConcept | ||
| Binding | Correspondence care setting type | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
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| Composition.extension:careSettingTypeExtension.value[x]:valueCodeableConcept.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
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| Composition.extension:careSettingTypeExtension.value[x]:valueCodeableConcept.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
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| Composition.extension:careSettingTypeExtension.value[x]:valueCodeableConcept.coding | |||
| Short | Code defined by a terminology system | ||
| Definition | A reference to a code defined by a terminology system. | ||
| Cardinality | 1..1 | ||
| Type | Coding | ||
| Summary | True | ||
| Requirements | Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. | ||
| Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Composition.extension:careSettingTypeExtension.value[x]:valueCodeableConcept.coding.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Composition.extension:careSettingTypeExtension.value[x]:valueCodeableConcept.coding.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
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| Composition.extension:careSettingTypeExtension.value[x]:valueCodeableConcept.coding.system | |||
| Short | Identity of the terminology system | ||
| Definition | The identification of the code system that defines the meaning of the symbol in the code. | ||
| Cardinality | 1..1 | ||
| Type | uri | ||
| Summary | True | ||
| Requirements | Need to be unambiguous about the source of the definition of the symbol. | ||
| Comments | The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Fixed Value | http://snomed.info/sct | ||
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| Composition.extension:careSettingTypeExtension.value[x]:valueCodeableConcept.coding.version | |||
| Short | Version of the system - if relevant | ||
| Definition | The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. | ||
| Cardinality | 0..0 | ||
| Type | string | ||
| Summary | True | ||
| Comments | Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
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| Composition.extension:careSettingTypeExtension.value[x]:valueCodeableConcept.coding.code | |||
| Short | Symbol in syntax defined by the system | ||
| Definition | A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). | ||
| Cardinality | 1..1 | ||
| Type | code | ||
| Summary | True | ||
| Requirements | Need to refer to a particular code in the system. | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
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| Composition.extension:careSettingTypeExtension.value[x]:valueCodeableConcept.coding.display | |||
| Short | Representation defined by the system | ||
| Definition | A representation of the meaning of the code in the system, following the rules of the system. | ||
| Cardinality | 1..1 | ||
| Type | string | ||
| Summary | True | ||
| Requirements | Need to be able to carry a human-readable meaning of the code for readers that do not know the system. | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.extension:careSettingTypeExtension.value[x]:valueCodeableConcept.coding.userSelected | |||
| Short | If this coding was chosen directly by the user | ||
| Definition | Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). | ||
| Cardinality | 0..0 | ||
| Type | boolean | ||
| Summary | True | ||
| Requirements | This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. | ||
| Comments | Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.extension:careSettingTypeExtension.value[x]:valueCodeableConcept.text | |||
| Short | Plain text representation of the concept | ||
| Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. | ||
| Cardinality | 0..0 | ||
| Type | string | ||
| Summary | True | ||
| Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. | ||
| Comments | Very often the text is the same as a displayName of one of the codings. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.modifierExtension | |||
| Short | Extensions that cannot be ignored | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Modifier | True | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
| ||
| Mappings |
| ||
| Composition.identifier | |||
| Short | Logical identifier of composition (version-independent) | ||
| Definition | Logical identifier for the composition, assigned when created. This identifier stays constant as the composition is changed over time. | ||
| Cardinality | 0..1 | ||
| Type | Identifier | ||
| Summary | True | ||
| Comments | See discussion in resource definition for how these relate. | ||
| Slicing | Unordered, Open, by system(Value) | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
| ||
| Mappings |
| ||
| Composition.identifier.use | |||
| Short | usual | official | temp | secondary (If known) | ||
| Definition | The purpose of this identifier. | ||
| Cardinality | 0..1 | ||
| Type | code | ||
| Binding | Identifies the purpose for this identifier, if known . | ||
| Modifier | True | ||
| Summary | True | ||
| Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. | ||
| Comments | This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier.type | |||
| Short | Description of identifier | ||
| Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. | ||
| Cardinality | 0..1 | ||
| Type | CodeableConcept | ||
| Binding | A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||
| Summary | True | ||
| Requirements | Allows users to make use of identifiers when the identifier system is not known. | ||
| Comments | This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier.system | |||
| Short | The namespace for the identifier value | ||
| Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. | ||
| Cardinality | 1..1 | ||
| Type | uri | ||
| Summary | True | ||
| Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. | ||
| Comments | see http://en.wikipedia.org/wiki/Uniform_resource_identifier | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Examples | Generalhttp://www.acme.com/identifiers/patient | ||
| Mappings |
| ||
| Composition.identifier.value | |||
| Short | The value that is unique | ||
| Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system. | ||
| Cardinality | 1..1 | ||
| Type | string | ||
| Summary | True | ||
| Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Examples | General123456 | ||
| Mappings |
| ||
| Composition.identifier.period | |||
| Short | Time period when id is/was valid for use | ||
| Definition | Time period during which identifier is/was valid for use. | ||
| Cardinality | 0..1 | ||
| Type | Period | ||
| Summary | True | ||
| Comments | This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval|Duration. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier.assigner | |||
| Short | Organization that issued id (may be just text) | ||
| Definition | Organization that issued/manages the identifier. | ||
| Cardinality | 0..1 | ||
| Type | Reference(CareConnect-Organization-1) | ||
| Summary | True | ||
| Comments | The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier:crossCareSettingIdentifier | |||
| Short | Logical identifier of composition (version-independent) | ||
| Definition | Logical identifier for the composition, assigned when created. This identifier stays constant as the composition is changed over time. | ||
| Cardinality | 1..1 | ||
| Type | Identifier | ||
| Summary | True | ||
| Comments | See discussion in resource definition for how these relate. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier:crossCareSettingIdentifier.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier:crossCareSettingIdentifier.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
| ||
| Mappings |
| ||
| Composition.identifier:crossCareSettingIdentifier.use | |||
| Short | usual | official | temp | secondary (If known) | ||
| Definition | The purpose of this identifier. | ||
| Cardinality | 0..1 | ||
| Type | code | ||
| Binding | Identifies the purpose for this identifier, if known . | ||
| Modifier | True | ||
| Summary | True | ||
| Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. | ||
| Comments | This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier:crossCareSettingIdentifier.type | |||
| Short | Description of identifier | ||
| Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. | ||
| Cardinality | 0..1 | ||
| Type | CodeableConcept | ||
| Binding | A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||
| Summary | True | ||
| Requirements | Allows users to make use of identifiers when the identifier system is not known. | ||
| Comments | This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier:crossCareSettingIdentifier.system | |||
| Short | The namespace for the identifier value | ||
| Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. | ||
| Cardinality | 1..1 | ||
| Type | uri | ||
| Summary | True | ||
| Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. | ||
| Comments | see http://en.wikipedia.org/wiki/Uniform_resource_identifier | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Fixed Value | https://fhir.nhs.uk/Id/cross-care-setting-identifier | ||
| Examples | Generalhttp://www.acme.com/identifiers/patient | ||
| Mappings |
| ||
| Composition.identifier:crossCareSettingIdentifier.value | |||
| Short | The value that is unique | ||
| Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system. | ||
| Cardinality | 1..1 | ||
| Type | string | ||
| Summary | True | ||
| Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Examples | General123456 | ||
| Mappings |
| ||
| Composition.identifier:crossCareSettingIdentifier.period | |||
| Short | Time period when id is/was valid for use | ||
| Definition | Time period during which identifier is/was valid for use. | ||
| Cardinality | 0..1 | ||
| Type | Period | ||
| Summary | True | ||
| Comments | This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval|Duration. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier:crossCareSettingIdentifier.assigner | |||
| Short | Organization that issued id (may be just text) | ||
| Definition | Organization that issued/manages the identifier. | ||
| Cardinality | 0..1 | ||
| Type | Reference(CareConnect-Organization-1 | CareConnect-GPC-Organization-1) | ||
| Summary | True | ||
| Comments | The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier:identifier | |||
| Short | Logical identifier of composition (version-independent) | ||
| Definition | Logical identifier for the composition, assigned when created. This identifier stays constant as the composition is changed over time. | ||
| Cardinality | 0..1 | ||
| Type | Identifier | ||
| Summary | True | ||
| Comments | See discussion in resource definition for how these relate. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier:identifier.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier:identifier.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
| ||
| Mappings |
| ||
| Composition.identifier:identifier.use | |||
| Short | usual | official | temp | secondary (If known) | ||
| Definition | The purpose of this identifier. | ||
| Cardinality | 0..1 | ||
| Type | code | ||
| Binding | Identifies the purpose for this identifier, if known . | ||
| Modifier | True | ||
| Summary | True | ||
| Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. | ||
| Comments | This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier:identifier.type | |||
| Short | Description of identifier | ||
| Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. | ||
| Cardinality | 0..1 | ||
| Type | CodeableConcept | ||
| Binding | A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||
| Summary | True | ||
| Requirements | Allows users to make use of identifiers when the identifier system is not known. | ||
| Comments | This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier:identifier.system | |||
| Short | The namespace for the identifier value | ||
| Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. | ||
| Cardinality | 1..1 | ||
| Type | uri | ||
| Summary | True | ||
| Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. | ||
| Comments | see http://en.wikipedia.org/wiki/Uniform_resource_identifier | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Examples | Generalhttp://www.acme.com/identifiers/patient | ||
| Mappings |
| ||
| Composition.identifier:identifier.value | |||
| Short | The value that is unique | ||
| Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system. | ||
| Cardinality | 1..1 | ||
| Type | string | ||
| Summary | True | ||
| Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Examples | General123456 | ||
| Mappings |
| ||
| Composition.identifier:identifier.period | |||
| Short | Time period when id is/was valid for use | ||
| Definition | Time period during which identifier is/was valid for use. | ||
| Cardinality | 0..1 | ||
| Type | Period | ||
| Summary | True | ||
| Comments | This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval|Duration. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.identifier:identifier.assigner | |||
| Short | Organization that issued id (may be just text) | ||
| Definition | Organization that issued/manages the identifier. | ||
| Cardinality | 0..1 | ||
| Type | Reference(CareConnect-Organization-1 | CareConnect-GPC-Organization-1) | ||
| Summary | True | ||
| Comments | The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.status | |||
| Short | preliminary | final | amended | entered-in-error | ||
| Definition | The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. | ||
| Cardinality | 1..1 | ||
| Type | code | ||
| Binding | The workflow/clinical status of the composition. | ||
| Modifier | True | ||
| Summary | True | ||
| Requirements | Need to be able to mark interim, amended, or withdrawn compositions or documents. | ||
| Comments | If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Fixed Value | final | ||
| Mappings |
| ||
| Composition.type | |||
| Short | Kind of composition (SNOMED CT) | ||
| Definition | Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. | ||
| Cardinality | 1..1 | ||
| Type | CodeableConcept | ||
| Binding | SNOMED CT Document Type | ||
| Summary | True | ||
| Requirements | Key metadata element describing the composition, used in searching/filtering. | ||
| Comments | For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.type.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.type.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
| ||
| Mappings |
| ||
| Composition.type.coding | |||
| Short | Code defined by a terminology system | ||
| Definition | A reference to a code defined by a terminology system. | ||
| Cardinality | 1..* | ||
| Type | Coding | ||
| Summary | True | ||
| Requirements | Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. | ||
| Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.type.coding.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.type.coding.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
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| Mappings |
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| Composition.type.coding.system | |||
| Short | Identity of the terminology system | ||
| Definition | The identification of the code system that defines the meaning of the symbol in the code. | ||
| Cardinality | 1..1 | ||
| Type | uri | ||
| Summary | True | ||
| Requirements | Need to be unambiguous about the source of the definition of the symbol. | ||
| Comments | The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Fixed Value | http://snomed.info/sct | ||
| Mappings |
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| Composition.type.coding.version | |||
| Short | Version of the system - if relevant | ||
| Definition | The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. | ||
| Cardinality | 0..0 | ||
| Type | string | ||
| Summary | True | ||
| Comments | Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.type.coding.code | |||
| Short | Symbol in syntax defined by the system | ||
| Definition | A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). | ||
| Cardinality | 1..1 | ||
| Type | code | ||
| Summary | True | ||
| Requirements | Need to refer to a particular code in the system. | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Fixed Value | 325851000000107 | ||
| Mappings |
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| Composition.type.coding.display | |||
| Short | Representation defined by the system | ||
| Definition | A representation of the meaning of the code in the system, following the rules of the system. | ||
| Cardinality | 1..1 | ||
| Type | string | ||
| Summary | True | ||
| Requirements | Need to be able to carry a human-readable meaning of the code for readers that do not know the system. | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Fixed Value | Consultation | ||
| Mappings |
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| Composition.type.coding.userSelected | |||
| Short | If this coding was chosen directly by the user | ||
| Definition | Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). | ||
| Cardinality | 0..0 | ||
| Type | boolean | ||
| Summary | True | ||
| Requirements | This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. | ||
| Comments | Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.type.text | |||
| Short | Plain text representation of the concept | ||
| Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Summary | True | ||
| Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. | ||
| Comments | Very often the text is the same as a displayName of one of the codings. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.class | |||
| Short | 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. | ||
| Cardinality | 0..1 | ||
| Type | CodeableConcept | ||
| Binding | High-level kind of a clinical document at a macro level. | ||
| Summary | True | ||
| 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. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.subject | |||
| Short | Who and/or what the composition is about | ||
| Definition | Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). | ||
| Cardinality | 1..1 | ||
| Type | Reference(CareConnect-GPC-Patient-1) | ||
| Summary | True | ||
| 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. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.encounter | |||
| Short | Context of the Composition | ||
| Definition | Describes the clinical encounter or type of care this documentation is associated with. | ||
| Cardinality | 1..1 | ||
| Type | Reference(CareConnect-GPC-Encounter-1) | ||
| Summary | True | ||
| Requirements | Provides context for the composition and supports searching. | ||
| Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.date | |||
| Short | Composition editing time | ||
| Definition | The composition editing time, when the composition was last logically changed by the author. | ||
| Cardinality | 1..1 | ||
| Type | dateTime | ||
| Summary | True | ||
| Requirements | dateTime is used for tracking, organizing versions and searching. | ||
| Comments | The Last Modified Date on the composition may be after the date of the document was attested without being changed. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.author | |||
| Short | Who and/or what authored the composition | ||
| Definition | Identifies who is responsible for the information in the composition, not necessarily who typed it in. | ||
| Cardinality | 1..* | ||
| Type | Reference(Device | RelatedPerson | CareConnect-Patient-1 | CareConnect-GPC-Practitioner-1) | ||
| Summary | True | ||
| 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. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.title | |||
| Short | Human Readable name/title | ||
| Definition | Official human-readable label for the composition. | ||
| Cardinality | 1..1 | ||
| Type | string | ||
| Summary | True | ||
| 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. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.confidentiality | |||
| Short | As defined by affinity domain | ||
| Definition | The code specifying the level of confidentiality of the Composition. | ||
| Cardinality | 0..0 | ||
| Type | code | ||
| Binding | Codes specifying the level of confidentiality of the composition. | ||
| Modifier | True | ||
| Summary | True | ||
| 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. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.attester | |||
| Short | Attests to accuracy of composition | ||
| Definition | A participant who has attested to the accuracy of the composition/document. | ||
| Cardinality | 0..0 | ||
| Type | BackboneElement | ||
| Summary | True | ||
| Requirements | Identifies responsibility for the accuracy of the composition content. | ||
| Comments | Only list each attester once. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.attester.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.attester.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
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| Mappings |
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| Composition.attester.modifierExtension | |||
| Short | Extensions that cannot be ignored | ||
| 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 that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Modifier | True | ||
| Summary | True | ||
| Alias | extensions, user content, modifiers | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.attester.mode | |||
| Short | personal | professional | legal | official | ||
| Definition | The type of attestation the authenticator offers. | ||
| Cardinality | 1..* | ||
| Type | code | ||
| Binding | The way in which a person authenticated a composition. | ||
| Summary | True | ||
| Requirements | Indicates the level of authority of the attestation. | ||
| Comments | Use more than one code where a single attester has more than one mode (professional and legal are often paired). | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.attester.time | |||
| Short | When the composition was attested | ||
| Definition | When the composition was attested by the party. | ||
| Cardinality | 0..1 | ||
| Type | dateTime | ||
| Summary | True | ||
| Requirements | Identifies when the information in the composition was deemed accurate. (Things may have changed since then.). | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.attester.party | |||
| Short | Who attested the composition | ||
| Definition | Who attested the composition in the specified way. | ||
| Cardinality | 0..1 | ||
| Type | Reference(CareConnect-Organization-1 | CareConnect-Patient-1 | CareConnect-Practitioner-1) | ||
| Summary | True | ||
| Requirements | Identifies who has taken on the responsibility for accuracy of the composition content. | ||
| Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.custodian | |||
| Short | 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. | ||
| Cardinality | 0..0 | ||
| Type | Reference(CareConnect-Organization-1) | ||
| Summary | True | ||
| 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. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.relatesTo | |||
| Short | Relationships to other compositions/documents | ||
| Definition | Relationships that this composition has with other compositions or documents that already exist. | ||
| Cardinality | 0..0 | ||
| Type | BackboneElement | ||
| Summary | True | ||
| Comments | A document is a version specific composition. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.relatesTo.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.relatesTo.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
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| Mappings |
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| Composition.relatesTo.modifierExtension | |||
| Short | Extensions that cannot be ignored | ||
| 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 that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Modifier | True | ||
| Summary | True | ||
| Alias | extensions, user content, modifiers | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.relatesTo.code | |||
| Short | replaces | transforms | signs | appends | ||
| Definition | The type of relationship that this composition has with anther composition or document. | ||
| Cardinality | 1..1 | ||
| Type | code | ||
| Binding | The type of relationship between documents. | ||
| Summary | True | ||
| Comments | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.relatesTo.target[x] | |||
| Short | Target of the relationship | ||
| Definition | The target composition/document of this relationship. | ||
| Cardinality | 1..1 | ||
| Type | Identifier | Reference(CareConnect-Composition-1) | ||
| Summary | True | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.event | |||
| Short | The clinical service(s) being documented | ||
| Definition | The clinical service, such as a colonoscopy or an appendectomy, being documented. | ||
| Cardinality | 0..0 | ||
| Type | BackboneElement | ||
| Summary | True | ||
| 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. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.event.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.event.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
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| Mappings |
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| Composition.event.modifierExtension | |||
| Short | Extensions that cannot be ignored | ||
| 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 that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Modifier | True | ||
| Summary | True | ||
| Alias | extensions, user content, modifiers | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.event.code | |||
| Short | 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. | ||
| Cardinality | 0..* | ||
| Type | CodeableConcept | ||
| Binding | This list of codes represents the main clinical acts being documented. | ||
| Summary | True | ||
| 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. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.event.period | |||
| Short | 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. | ||
| Cardinality | 0..1 | ||
| Type | Period | ||
| Summary | True | ||
| Comments | This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval|Duration. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.event.detail | |||
| Short | 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. | ||
| Cardinality | 0..* | ||
| Type | Reference(Resource) | ||
| Summary | True | ||
| 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. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.section | |||
| Short | Composition is broken into sections | ||
| Definition | The root of the sections that make up the composition. | ||
| Cardinality | 1..* | ||
| Type | BackboneElement | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.section.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
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| Mappings |
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| Composition.section.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
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| Mappings |
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| Composition.section.extension:problemReference | |||
| Short | An extension to allow resolution of problem link to composition section. | ||
| Definition | An extension to allow resolution of the problem link to composition section - will be back reference to problem id … nb this is in the 1st instance intended to be used to resolve the problem reference e.g. problem references composition and consumer must then look for the section with the id that corresponds to the problem to make the linkage | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.extension:problemReference.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.extension:problemReference.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
| ||
| Mappings |
| ||
| Composition.section.extension:problemReference.url | |||
| Short | identifies the meaning of the extension | ||
| Definition | Source of the definition for the extension code - a logical name or a URL. | ||
| Cardinality | 1..1 | ||
| Type | uri | ||
| Comments | The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Fixed Value | http://hl7.org/fhir/STU3/extension-valueset-reference.html | ||
| Mappings |
| ||
| Composition.section.extension:problemReference.value[x] | |||
| Short | Value of extension | ||
| Definition | Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list). | ||
| Cardinality | 0..1 | ||
| Type | Address | Age | Annotation | Attachment | base64Binary | boolean | code | CodeableConcept | Coding | ContactPoint | Count | date | dateTime | decimal | Distance | Duration | HumanName | id | Identifier | instant | integer | markdown | Meta | Money | oid | Period | positiveInt | Quantity | Range | Ratio | Reference | SampledData | Signature | string | time | Timing | unsignedInt | uri | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.modifierExtension | |||
| Short | Extensions that cannot be ignored | ||
| 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 that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Modifier | True | ||
| Summary | True | ||
| Alias | extensions, user content, modifiers | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.title | |||
| Short | Label for section (e.g. for ToC) | ||
| 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. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Alias | header, label, caption | ||
| Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||
| Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.code | |||
| Short | Classification of section (recommended) | ||
| Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title. | ||
| Cardinality | 1..1 | ||
| Type | CodeableConcept | ||
| Binding | Classification of a section of a composition/document. | ||
| Requirements | Provides computable standardized labels to topics within the document. | ||
| Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.code.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.code.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
| ||
| Mappings |
| ||
| Composition.section.code.coding | |||
| Short | Code defined by a terminology system | ||
| Definition | A reference to a code defined by a terminology system. | ||
| Cardinality | 1..* | ||
| Type | Coding | ||
| Summary | True | ||
| Requirements | Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. | ||
| Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.code.coding.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.code.coding.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
| ||
| Mappings |
| ||
| Composition.section.code.coding.system | |||
| Short | Identity of the terminology system | ||
| Definition | The identification of the code system that defines the meaning of the symbol in the code. | ||
| Cardinality | 1..1 | ||
| Type | uri | ||
| Summary | True | ||
| Requirements | Need to be unambiguous about the source of the definition of the symbol. | ||
| Comments | The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Fixed Value | http://snomed.info/sct | ||
| Mappings |
| ||
| Composition.section.code.coding.version | |||
| Short | Version of the system - if relevant | ||
| Definition | The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. | ||
| Cardinality | 0..0 | ||
| Type | string | ||
| Summary | True | ||
| Comments | Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.code.coding.code | |||
| Short | Symbol in syntax defined by the system | ||
| Definition | A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). | ||
| Cardinality | 1..1 | ||
| Type | code | ||
| Summary | True | ||
| Requirements | Need to refer to a particular code in the system. | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Fixed Value | 25851000000105 | ||
| Mappings |
| ||
| Composition.section.code.coding.display | |||
| Short | Representation defined by the system | ||
| Definition | A representation of the meaning of the code in the system, following the rules of the system. | ||
| Cardinality | 1..1 | ||
| Type | string | ||
| Summary | True | ||
| Requirements | Need to be able to carry a human-readable meaning of the code for readers that do not know the system. | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Fixed Value | Topic (EHR) | ||
| Mappings |
| ||
| Composition.section.code.coding.userSelected | |||
| Short | If this coding was chosen directly by the user | ||
| Definition | Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). | ||
| Cardinality | 0..0 | ||
| Type | boolean | ||
| Summary | True | ||
| Requirements | This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. | ||
| Comments | Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.code.text | |||
| Short | Plain text representation of the concept | ||
| Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Summary | True | ||
| Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. | ||
| Comments | Very often the text is the same as a displayName of one of the codings. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.text | |||
| Short | 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. | ||
| Cardinality | 0..1 | ||
| Type | Narrative | ||
| Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.mode | |||
| Short | 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. | ||
| Cardinality | 1..1 | ||
| Type | code | ||
| Binding | The processing mode that applies to this section. | ||
| Modifier | True | ||
| Summary | True | ||
| 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 mis-understood as a complete list. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Fixed Value | snapshot | ||
| Mappings |
| ||
| Composition.section.orderedBy | |||
| Short | Order of section entries | ||
| Definition | Specifies the order applied to the items in the section entries. | ||
| Cardinality | 1..1 | ||
| Type | CodeableConcept | ||
| Binding | What order applies to the items in the entry. | ||
| 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. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.orderedBy.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.orderedBy.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
| ||
| Mappings |
| ||
| Composition.section.orderedBy.coding | |||
| Short | Code defined by a terminology system | ||
| Definition | A reference to a code defined by a terminology system. | ||
| Cardinality | 0..* | ||
| Type | Coding | ||
| Summary | True | ||
| Requirements | Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. | ||
| Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.orderedBy.coding.id | |||
| Short | xml:id (or equivalent in JSON) | ||
| Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.orderedBy.coding.extension | |||
| Short | Additional Content defined by implementations | ||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||
| Cardinality | 0..* | ||
| Type | Extension | ||
| Alias | extensions, user content | ||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||
| 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 |
| ||
| Mappings |
| ||
| Composition.section.orderedBy.coding.system | |||
| Short | Identity of the terminology system | ||
| Definition | The identification of the code system that defines the meaning of the symbol in the code. | ||
| Cardinality | 1..1 | ||
| Type | uri | ||
| Summary | True | ||
| Requirements | Need to be unambiguous about the source of the definition of the symbol. | ||
| Comments | The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Fixed Value | http://hl7.org/fhir/ValueSet/list-order | ||
| Mappings |
| ||
| Composition.section.orderedBy.coding.version | |||
| Short | Version of the system - if relevant | ||
| Definition | The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. | ||
| Cardinality | 0..0 | ||
| Type | string | ||
| Summary | True | ||
| Comments | Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.orderedBy.coding.code | |||
| Short | Symbol in syntax defined by the system | ||
| Definition | A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). | ||
| Cardinality | 0..1 | ||
| Type | code | ||
| Summary | True | ||
| Requirements | Need to refer to a particular code in the system. | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.orderedBy.coding.display | |||
| Short | Representation defined by the system | ||
| Definition | A representation of the meaning of the code in the system, following the rules of the system. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Summary | True | ||
| Requirements | Need to be able to carry a human-readable meaning of the code for readers that do not know the system. | ||
| Comments | Note that FHIR strings may not exceed 1MB in size | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.orderedBy.coding.userSelected | |||
| Short | If this coding was chosen directly by the user | ||
| Definition | Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). | ||
| Cardinality | 0..0 | ||
| Type | boolean | ||
| Summary | True | ||
| Requirements | This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. | ||
| Comments | Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.orderedBy.text | |||
| Short | Plain text representation of the concept | ||
| Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. | ||
| Cardinality | 0..1 | ||
| Type | string | ||
| Summary | True | ||
| Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. | ||
| Comments | Very often the text is the same as a displayName of one of the codings. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.entry | |||
| Short | A reference to data that supports this section | ||
| Definition | A reference to the actual resource from which the narrative in the section is derived. | ||
| Cardinality | 0..* | ||
| Type | Reference(ReferralRequest | CareConnect-GPC-AllergyIntolerance-1 | CareConnect-GPC-MedicationRequest-1 | CareConnect-GPC-Observation-1) | ||
| Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.emptyReason | |||
| Short | 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. | ||
| Cardinality | 0..0 | ||
| Type | CodeableConcept | ||
| Binding | If a section is empty, why it is empty. | ||
| 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. | ||
| Conditions | The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2 | ||
| Constraints |
| ||
| Mappings |
| ||
| Composition.section.section | |||
| Short | Nested Section | ||
| Definition | A nested sub-section within this section. | ||
| Cardinality | 0..* | ||
| Type | see (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 |
| ||
Data model element usage
| Element | Use | CareConnect | UK Core |
|---|---|---|---|
| id | |||
| meta.profile | |||
| meta.versionId | |||
| meta.lastUpdated | |||
| text | |||
| extension(careSettingTypeExtension) | |||
| identifier | |||
| status | |||
| type | |||
| class | |||
| subject | |||
| encounter | |||
| date | |||
| author | |||
| title | |||
| confidentiality | |||
| attester | |||
| custodian | |||
| relatesTo | |||
| event | |||
| section |
id
Usage
Mandatory
Guidance
The id is the logical identifier for the CareConnect-Composition-1 profile.
Example
<id value="c3ea1a42-5aba-11ed-9b6a-0242ac120002" />
meta.versionId
Usage
Optional
Guidance
This guidance currently relies on MESH as the sending mechanism and, as such, harnesses the MESH .CTL <version> element to indicate the version of the document that is being sent.
However, it is recommended that the meta.versionId element be populated with the version of the document that is being sent. This will be the same version as that populated in the the MESH .CTL file.
Example
<meta> <versionId value="1" /> </meta>
meta.lastUpdated
Usage
Optional
Guidance
The meta.lastUpdated element does not need to be populated.
Example
<meta> <lastUpdated value="2022-11-02T14:19:00+00:00" /> </meta>
meta.profile
Usage
Mandatory
Guidance
The meta.profile contains a fixed value of the URL for the CareConnect-GPC-Composition-1 profile.
Example
<meta> <profile value="https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-GPC-Composition-1" /> </meta>
meta.security
Usage
Optional
Guidance
The meta.security element does not need to be populated.
Example
<meta> <security> <coding> <system value="http://hl7.org/fhir/v3/Confidentiality" /> <code value="L" /> <display value="low" /> </coding> </security> </meta>
meta.tag
Usage
Optional
Guidance
The meta.tag element does not need to be populated for this capability.
Example
<meta> <tag> <coding> <system value="http://hl7.org/fhir/common-tags" /> <code value="actionable" /> <display value="Actionable" /> </coding> </tag> </meta>
extension(careSettingTypeExtension)
Usage
Optional
Guidance
A value from a set of SNOMED codes which can be used to describe a type of care setting that the document has come from (if available).
The SNOMED codes have been selected from the 'Services' simple reference set of the SNOMED CT UK coding system.
The most complete list for this valueset can be found in the NHS FHIR HL7 UK Core guidance below:
Simplifier https://simplifier.net/packages/ukcore.r4.02.00.00/2.0.0/files/365046
SNOMED CT Browser https://termbrowser.nhs.uk/?perspective=full&conceptId1=1127531000000102
Example
<extension url="https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-CareSettingType-1"> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct" /> <code value="983341000000102" /> <display value="Pharmacy First service (qualifier value)" /> </coding> </valueCodeableConcept> </extension>
identifier
Usage
Optional
Guidance
It is highly recommended that the logical id value is a Universally Unique Identifier (UUID) using a standard UUID generator available in most programming languages.
status
Usage
Mandatory
Guidance
At the time of writing, the codesystem for CompositionStatus contains the following:
preliminaryfinalamendedentered-in-error
View the up-to-date STU3 codesystem here
The diagram below represents how the composition can transition through the available statuses.
type
Usage
Mandatory
Guidance
The type of composition being supplied - a value from the Record composition type simple reference set (foundation metadata concept) is preferred.
Example
<coding> <system value="http://snomed.info/sct" /> <code value="1082101000000102" /> <display value="Investigation results (record artifact)" /> </coding>
class
Usage
Optional
Guidance
A use case for this element has not been defined at the time of writing this guidance.
subject
Usage
Mandatory
Guidance
The subject MUST contain a Patient resource profiled to the CareConnect-GPC-Patient-1 structure definition.
More information about how to populate this resource can be found in this guide using the link below.
encounter
Usage
Mandatory
Guidance
This element **MUST** be used to reference the encounter that this activity relates to.Example
```xmldate
Usage
Mandatory
Guidance
The date element MUST contain the date and time that the message was created.
title
Usage
Mandatory
Guidance
The title MUST contain a value in relation to the type of activity you are sending.
Example
<title value="[Insert Document Title Here]" />
attester
Usage
Optional
Guidance
At the time of writing this article, the attester element has not been defined; however, the Composition.attester.mode element may be pertinent for certain types of payloads, in relation to the information they contain.
A future version of this guidance may request that this element be used.
text
Usage
Optional
Guidance
A human-readable description of the payload being sent - using HTML.
Example
<text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"><p>[payload-title] for [patient-name], NHS Number: [nhs-number], seen at [practice-name], [ods-code], Version: [version-number]</p></div> </text>
confidentiality
Usage
Optional
Guidance
The confidentiality MUST contain one of the following values if used:
N(Normal)R(Restricted) - if the document is classed as confidential
Additional codes are defined by the base HL7 FHIR standard; however, guidance around how they should be interpreted cannot be defined at this time.
HL7 Value Set ConfidentialityClassification (v3)
Example
<!-- Normal --> <confidentiality value="N" /> <!-- Restricted --> <confidentiality value="R" />
relatesTo
Usage
Optional
Guidance
Used to determine whether the composition relates to another - for example, whether it "replaces" another.
Example
<relatesTo> <code value="replaces" /> <targetIdentifier value="e255cf10-db3c-11ec-9d64-0242ac120002" /> </relatesTo>
event
Usage
Optional
Guidance
Additional context about the event being sent within the composition.
Example
<event> <coding> <system value="http://snomed.info/sct" /> <code value="755491000000100" /> <display value="Diabetes structured education programme completed (situation) " /> </coding> </event>
section
Usage
Mandatory
Guidance
Entries relating to the composition being provided. At least one should be supplied.
Example
<section> <!-- CareConnect-GPC-Encounter-1 --> <entry> <reference value="urn:be36bcc0-1279-43ca-ae4e-2b1c5fc2e4fd" /> </entry> </section>