Ontario Clinical Report Exchange Implementation Guide v1.0.0

There are no (further) constraints on this element

Element id

Composition

Short description

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 package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).

Comments

While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.

Data type

Constraints

dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty()
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-6: A resource should have narrative for robust management
text.`div`.exists()
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty()

Mappings

rim: Entity. Role, or Act
workflow: Event
rim: Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
cda: ClinicalDocument
fhirdocumentreference: when described by DocumentReference

0..1

There are no (further) constraints on this element

Element id

Composition.id

Short description

Logical id of this artifact

Definition

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

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a

There are no (further) constraints on this element

Element id

Composition.meta

Short description

Metadata about the resource

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A

implicitRules

Σ ?!

0..1

There are no (further) constraints on this element

Element id

Composition.implicitRules

Short description

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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a

language

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.language

Short description

Language of the resource content

Definition

The base language in which the resource is written.

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).

Data type

Binding

A human language.

CommonLanguages (preferred)

Binding extensions

MaxValueSet	AllLanguages

Conditions

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

Constraints

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

Mappings

rim: n/a

text

0..1

There are no (further) constraints on this element

Element id

Composition.text

Short description

Text summary of the resource, for human interpretation

Alternate names

narrative, html, xhtml, display

Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: Act.text?

contained

0..*

There are no (further) constraints on this element

Element id

Composition.contained

Short description

Contained, inline Resources

Alternate names

inline resources, anonymous resources, contained 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.

Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Data type

Mappings

rim: Entity. Role, or Act
rim: N/A

extension

0..*

There are no (further) constraints on this element

Element id

Composition.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

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.

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

versionNumber

0..1

There are no (further) constraints on this element

Element id

Composition.extension:versionNumber

Short description

Version-specific identifier for composition

Alternate names

extensions, user content

Definition

Version specific identifier for the composition, assigned when each version is created/updated.

Comments

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

Data type

Extension URL

CDVersionNumber

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

?! C

0..*

There are no (further) constraints on this element

Element id

Composition.modifierExtension

Short description

Extensions that cannot be ignored

Alternate names

extensions, user content

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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

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

Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

identifier

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.identifier

Short description

identifier

Definition

A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
servd: Identifier
workflow: Event.identifier
w5: FiveWs.identifier
rim: Document.id / Document.setId
cda: .setId
fhirdocumentreference: DocumentReference.masterIdentifier

status

Σ ?!

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.status

Short description

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.

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.

Data type

Binding

The workflow/clinical status of the composition.

CompositionStatus (required)

Conditions

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

Constraints

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

Mappings

rim: n/a
workflow: Event.status
w5: FiveWs.status
rim: interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
cda: n/a
fhirdocumentreference: DocumentReference.status

type

S Σ

1..1

CodeableConceptBinding

Element id

Composition.type

Short description

Discharge Summary

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.

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.

Data type

DischargeSummaryDocumentTypeCode (required)

Binding

Type of a composition.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
workflow: Event.code
w5: FiveWs.class
rim: ./code
cda: .code
fhirdocumentreference: DocumentReference.type

category

0..*

There are no (further) constraints on this element

Element id

Composition.category

Short description

Categorization of Composition

Definition

A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

Requirements

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

Comments

This is a metadata field from XDS/MHD.

Data type

DocumentClassValueSet (example)

Binding

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

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
workflow: Event.subject
w5: FiveWs.class
rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
cda: n/a
fhirdocumentreference: DocumenttReference.category

subject

S Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.subject

Short description

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).

Requirements

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

Comments

For clinical documents, this is usually the patient.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.subject[x]
rim: .participation[typeCode="SBJ"].role[typeCode="PAT"]
cda: .recordTarget
fhirdocumentreference: DocumentReference.subject
w5: FiveWs.subject

encounter

S Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.encounter

Short description

Context of the Composition

Definition

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

Requirements

Provides context for the composition and supports searching.

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.context
w5: FiveWs.context
rim: unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
cda: .componentOf.encompassingEncounter
fhirdocumentreference: DocumentReference.context.encounter

date

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.date

Short description

date

Definition

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

Requirements

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
workflow: Event.occurrence[x]
w5: FiveWs.done[x]
rim: .effectiveTime[type="TS"]
cda: .effectiveTime
fhirdocumentreference: DocumentReference.content.attachment.date, DocumentReference.created

author

S Σ C

1..*

Reference(Device | RelatedPerson | PatientEHR | PractitionerEHR | PractitionerRoleEHR)

There are no (further) constraints on this element

Element id

Composition.author

Short description

Who and/or what authored the composition

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Reference(Device | RelatedPerson | PatientEHR | PractitionerEHR | PractitionerRoleEHR)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor
fhirdocumentreference: DocumentReference.agent

title

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.title

Short description

Document Title

Definition

Official human-readable label for the composition.

Comments

For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title
fhirdocumentreference: DocumentReference.description, DocumentReference.content.attachment.title

confidentiality

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.confidentiality

Short description

Use the confidentiality codes in Meta.security

Definition

Use the confidentiality codes in Meta.security (https://hl7.org/fhir/security-labels.html)

Comments

The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not.

Data type

v3.ConfidentialityClassification (required)

Binding

Codes specifying the level of confidentiality of the composition.

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: .confidentialityCode
cda: .confidentialityCode
fhirdocumentreference: DocumentReference.securityLabel

attester

0..*

There are no (further) constraints on this element

Element id

Composition.attester

Short description

Attests to accuracy of composition

Definition

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

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Data type

Slicing

Unordered, Open, by mode(Value)

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

(All Slices)

The requirements in this element apply to all slices

0..1

There are no (further) constraints on this element

Element id

Composition.attester.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

mode

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.attester.mode

Short description

personal | professional | legal | official

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The way in which a person authenticated a composition.

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

There are no (further) constraints on this element

Element id

Composition.attester.time

Short description

When the composition was attested

Definition

When the composition was attested by the party.

Requirements

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

0..1

Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)

There are no (further) constraints on this element

Element id

Composition.attester.party

Short description

Who attested the composition

Definition

Who attested the composition in the specified way.

Requirements

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

Comments

Data type

Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.witness
rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
cda: .authenticator.assignedEnttty

legal_attester

0..1

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester

Short description

attester

Definition

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

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

0..1

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

mode

1..1

codeBindingFixed Value

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.mode

Short description

mode

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The way in which a person authenticated a composition.

Conditions

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

Constraints

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

Fixed value

legal

Mappings

rim: n/a
rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.time

Short description

When the composition was attested

Definition

When the composition was attested by the party.

Requirements

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

S C

1..1

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.party

Short description

party

Definition

Who attested the composition in the specified way.

Requirements

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

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.witness
rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
cda: .authenticator.assignedEnttty

professional_attester

0..*

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester

Short description

attester

Definition

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

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

0..1

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

mode

1..1

codeBindingFixed Value

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.mode

Short description

mode

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The way in which a person authenticated a composition.

Conditions

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

Constraints

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

Fixed value

professional

Mappings

rim: n/a
rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.time

Short description

When the composition was attested

Definition

When the composition was attested by the party.

Requirements

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

S C

1..1

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.party

Short description

party

Definition

Who attested the composition in the specified way.

Requirements

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

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.witness
rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
cda: .authenticator.assignedEnttty

personal_attester

0..*

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester

Short description

attester

Definition

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

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

0..1

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

mode

1..1

codeBindingFixed Value

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.mode

Short description

mode

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The way in which a person authenticated a composition.

Conditions

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

Constraints

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

Fixed value

personal

Mappings

rim: n/a
rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.time

Short description

When the composition was attested

Definition

When the composition was attested by the party.

Requirements

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

S C

1..1

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.party

Short description

party

Definition

Who attested the composition in the specified way.

Requirements

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

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.witness
rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
cda: .authenticator.assignedEnttty

custodian

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.custodian

Short description

Organization which maintains the composition

Definition

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

Requirements

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

Comments

This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
cda: .custodian.assignedCustodian
fhirdocumentreference: DocumentReference.custodian

relatesTo

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo

Short description

Relationships to other compositions/documents

Definition

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

Comments

A document is a version specific composition.

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: .outboundRelationship
cda: .relatedDocument
fhirdocumentreference: DocumentReference.relatesTo

0..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

code

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.relatesTo.code

Short description

replaces | transforms | signs | appends

Definition

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

Comments

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

Data type

DocumentRelationshipType (required)

Binding

The type of relationship between documents.

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: .outboundRelationship.typeCode
cda: .relatedDocument.typeCode
fhirdocumentreference: DocumentReference.relatesTo.code

target[x]

1..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.target[x]

Short description

Target of the relationship

Definition

The target composition/document of this relationship.

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: .target[classCode="DOC", moodCode="EVN"].id
cda: .relatedDocument.id
fhirdocumentreference: DocumentReference.relatesTo.target

targetIdentifier

There are no (further) constraints on this element

Data type

targetReference

There are no (further) constraints on this element

Data type

event

0..*

There are no (further) constraints on this element

Element id

Composition.event

Short description

The clinical service(s) being documented

Definition

The clinical service, such as a colonoscopy or an appendectomy, being documented.

Requirements

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

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
cda: .documentationOf.serviceEvent
fhirdocumentreference: DocumentReference.event

0..1

There are no (further) constraints on this element

Element id

Composition.event.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.event.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

code

0..*

There are no (further) constraints on this element

Element id

Composition.event.code

Short description

Code(s) that apply to the event being documented

Definition

This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.

Comments

An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries.

Data type

Binding

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

ActCode (example)

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .code
cda: .code
fhirdocumentreference: DocumentReference.event.code

period

Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.event.period

Short description

The period covered by the documentation

Definition

The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.

Comments

A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times").

Period is not used for a duration (a measure of elapsed time). See Duration.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
per-1: If present, start SHALL have a lower value than end
start.hasValue().not() or end.hasValue().not() or (start <= end)

Mappings

rim: n/a
v2: DR
rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
rim: .effectiveTime
cda: .effectiveTime
fhirdocumentreference: DocumentReference.event.period

detail

Σ C

0..*

There are no (further) constraints on this element

Element id

Composition.event.detail

Short description

The event(s) being documented

Definition

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

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode="SUBJ"].target
cda: n/a

section

3..*

Element id

Composition.section

Short description

Composition is broken into sections

Definition

The root of the sections that make up the composition.

Data type

Slicing

Unordered, Open, by code(Value)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

(All Slices)

The requirements in this element apply to all slices

0..1

There are no (further) constraints on this element

Element id

Composition.section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

0..1

There are no (further) constraints on this element

Element id

Composition.section.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

0..1

There are no (further) constraints on this element

Element id

Composition.section.code

Short description

Classification of section (recommended)

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section.focus

Short description

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

Definition

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

0..1

There are no (further) constraints on this element

Element id

Composition.section.text

Short description

Text summary of the section, for human interpretation

Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section.mode

Short description

working | snapshot | changes

Definition

How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section.entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

allergies_and_intolerances_section

S C

1..1

Element id

Composition.section:allergies_and_intolerances_section

Short description

Allergies and Intolerances Section

Definition

The root of the sections that make up the composition.

Comments

Allergies and Intolerances Section

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:allergies_and_intolerances_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:allergies_and_intolerances_section.code

Short description

Allergies and adverse reactions

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:allergies_and_intolerances_section.text

Short description

text

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:allergies_and_intolerances_section.entry

Short description

entry

Definition

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

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

allergy_entry

S C

0..*

Element id

Composition.section:allergies_and_intolerances_section.entry:allergy_entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

hospital_course_section

S C

1..1

Element id

Composition.section:hospital_course_section

Short description

Hospital Course Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_course_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_course_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "8648-8"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_course_section.text

Short description

This section contains only human readable content

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

discharge_diagnosis_section

S C

1..1

Element id

Composition.section:discharge_diagnosis_section

Short description

Discharge Diagnosis Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:discharge_diagnosis_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:discharge_diagnosis_section.code

Short description

Hospital discharge diagnosis

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11535-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:discharge_diagnosis_section.text

Short description

text

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:discharge_diagnosis_section.entry

Short description

entry

Definition

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

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

discharge_diagnosis_entry

S C

0..*

Element id

Composition.section:discharge_diagnosis_section.entry:discharge_diagnosis_entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

plan_of_treatment_section

S C

0..1

Element id

Composition.section:plan_of_treatment_section

Short description

Plan of Treatment Section

Definition

The root of the sections that make up the composition.

Comments

Plan of Treatment Section

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:plan_of_treatment_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:plan_of_treatment_section.code

Short description

Plan of treatment

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:plan_of_treatment_section.text

Short description

text

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:plan_of_treatment_section.entry

Short description

entry

Definition

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

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

sliceEntry

0..*

Element id

Composition.section:plan_of_treatment_section.entry:sliceEntry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

discharge_medications_section

S C

0..1

Element id

Composition.section:discharge_medications_section

Short description

Discharge Medications Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:discharge_medications_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:discharge_medications_section.code

Short description

Hospital discharge medications

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10183-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:discharge_medications_section.text

Short description

text

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:discharge_medications_section.entry

Short description

entry

Definition

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

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

discharge_medications_entry

S C

0..*

Reference(Medication | MedicationRequest | MedicationStatement)

Element id

Composition.section:discharge_medications_section.entry:discharge_medications_entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Reference(Medication | MedicationRequest | MedicationStatement)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

admission_diagnosis_section

S C

0..1

Element id

Composition.section:admission_diagnosis_section

Short description

Admission Diagnosis Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:admission_diagnosis_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:admission_diagnosis_section.code

Short description

Hospital admission diagnosis

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "46241-6"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:admission_diagnosis_section.text

Short description

text

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:admission_diagnosis_section.entry

Short description

entry

Definition

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

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

admission_diagnosis_entry

S C

0..*

Element id

Composition.section:admission_diagnosis_section.entry:admission_diagnosis_entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

admission_medications_section

S C

0..1

Element id

Composition.section:admission_medications_section

Short description

Admission Medications Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:admission_medications_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:admission_medications_section.code

Short description

Medications on admission

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "42346-7"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:admission_medications_section.text

Short description

text

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:admission_medications_section.entry

Short description

entry

Definition

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

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

admission_medications_entry

S C

0..*

Reference(Medication | MedicationRequest | MedicationStatement)

Element id

Composition.section:admission_medications_section.entry:admission_medications_entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Reference(Medication | MedicationRequest | MedicationStatement)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

chief_complaint_and_reason_for_visit_section

S C

0..1

Element id

Composition.section:chief_complaint_and_reason_for_visit_section

Short description

Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patientâs own description) and/or the reason for the patient's visit (the providerâs description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "46239-0"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.text

Short description

This section contains only human readable content

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

chief_complaint_section

S C

0..1

Element id

Composition.section:chief_complaint_section

Short description

Chief Complaint Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:chief_complaint_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:chief_complaint_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10154-3"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:chief_complaint_section.text

Short description

This section contains only human readable content

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

family_history_section

S C

0..1

Element id

Composition.section:family_history_section

Short description

Family History Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:family_history_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:family_history_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10157-6"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:family_history_section.text

Short description

text

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:family_history_section.entry

Short description

entry

Definition

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

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

family_history_entry

S C

0..*

Element id

Composition.section:family_history_section.entry:family_history_entry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

functional_status_section

S C

0..1

Element id

Composition.section:functional_status_section

Short description

Functional Status Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:functional_status_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:functional_status_section.code

Short description

Functional status

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:functional_status_section.text

Short description

text

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:functional_status_section.entry

Short description

entry

Definition

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

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

functional_status_entry

S C

0..*

Reference(ClinicalImpression | Observation | ConditionEHR)

Element id

Composition.section:functional_status_section.entry:functional_status_entry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

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

Comments

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

Data type

Reference(ClinicalImpression | Observation | ConditionEHR)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

history_of_present_illness_section

S C

0..1

Element id

Composition.section:history_of_present_illness_section

Short description

History of Present Illness Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:history_of_present_illness_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:history_of_present_illness_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10164-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:history_of_present_illness_section.text

Short description

This section contains only human readable content

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

hospital_consultations_section

S C

0..1

Element id

Composition.section:hospital_consultations_section

Short description

Hospital Consultations Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_consultations_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_consultations_section.code

Short description

Hospital consultations

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "18841-7"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_consultations_section.text

Short description

This section contains only human readable content

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

hospital_discharge_instructions_section

S C

0..1

Element id

Composition.section:hospital_discharge_instructions_section

Short description

Hospital Discharge Instructions Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_discharge_instructions_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_discharge_instructions_section.code

Short description

Hospital discharge instructions

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "8653-8"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_discharge_instructions_section.text

Short description

This section contains only human readable content

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

hospital_discharge_physical_section

S C

0..1

Element id

Composition.section:hospital_discharge_physical_section

Short description

Hospital Discharge Physical Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_discharge_physical_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_discharge_physical_section.code

Short description

Hospital discharge physical

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10184-0"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_discharge_physical_section.text

Short description

This section contains only human readable content

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

hospital_discharge_studies_section

S C

0..1

Element id

Composition.section:hospital_discharge_studies_section

Short description

Hospital Discharge Studies Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_discharge_studies_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_discharge_studies_section.code

Short description

Hospital discharge studies summary

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11493-4"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_discharge_studies_section.text

Short description

This section contains only human readable content

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.emptyReason

Short description

Why the section is empty

Definition

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

Requirements

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

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

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

Conditions

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

Mappings

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

immunizations_section

S C

0..1

Element id

Composition.section:immunizations_section

Short description

Immunizations Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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

Requirements

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:immunizations_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

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

Comments

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:immunizations_section.code

Short description

Immunizations

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

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

Constraints

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

Pattern

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.focus

Short description

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

Definition

Comments

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:immunizations_section.text

Short description

text

Definition

Comments

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

Data type

Conditions

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

Constraints

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

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.mode

Short description

working | snapshot | changes

Definition

Requirements

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

Comments

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

Data type

Binding

The processing mode that applies to this section.

Conditions

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

Constraints

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

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.orderedBy

Short description

Order of section entries

Definition

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

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

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

Constraints

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

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:immunizations_section.entry

Short description

entry

Definition

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

Comments

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

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

immunizations_entry

S C

0..*

Element id

Composition.section:immunizations_section.entry:immunizations_entry

Short description

A reference to data that supports this section

Definition

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

Comments

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

Data type

Conditions

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

nutrition_section

S C

0..1

Element id

Composition.section:nutrition_section

Short description

Nutrition Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:nutrition_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:nutrition_section.code

Short description

Diet and nutrition

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "61144-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:nutrition_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:nutrition_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

nutrition_entry

S C

0..*

Element id

Composition.section:nutrition_section.entry:nutrition_entry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

past_medical_history_section

S C

0..1

Element id

Composition.section:past_medical_history_section

Short description

Past Medical History Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:past_medical_history_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:past_medical_history_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11348-0"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:past_medical_history_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:past_medical_history_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

past_medical_history_entry

S C

0..*

Element id

Composition.section:past_medical_history_section.entry:past_medical_history_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

problem_section

S C

0..1

Element id

Composition.section:problem_section

Short description

Problem Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:problem_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:problem_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:problem_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:problem_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:problem_section.code

Short description

Problem list

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11450-4"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:problem_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:problem_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:problem_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:problem_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:problem_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:problem_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

problem_entry

S C

0..*

Element id

Composition.section:problem_section.entry:problem_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:problem_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:problem_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

procedures_section

S C

0..1

Element id

Composition.section:procedures_section

Short description

Procedures Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:procedures_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:procedures_section.code

Short description

History of procedures

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "47519-4"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:procedures_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:procedures_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

procedure_entry

S C

0..*

Element id

Composition.section:procedures_section.entry:procedure_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

reason_for_visit_section

S C

0..1

Element id

Composition.section:reason_for_visit_section

Short description

Reason for Visit Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:reason_for_visit_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:reason_for_visit_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "29299-5"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:reason_for_visit_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

review_of_systems_section

S C

0..1

Element id

Composition.section:review_of_systems_section

Short description

Review of Systems Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:review_of_systems_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:review_of_systems_section.code

Short description

Review of systems

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10187-3"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:review_of_systems_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

social_history_section

S C

0..1

Element id

Composition.section:social_history_section

Short description

Social History Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:social_history_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:social_history_section.code

Short description

Social history

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "29762-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:social_history_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:social_history_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

smoking_status_entry

S C

0..*

Element id

Composition.section:social_history_section.entry:smoking_status_entry

Short description

Smoking status

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

vital_signs_section

S C

0..1

Element id

Composition.section:vital_signs_section

Short description

Vital Signs Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:vital_signs_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:vital_signs_section.code

Short description

Vital signs

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "8716-3"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:vital_signs_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:vital_signs_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

vital_signs_entry

S C

0..*

Element id

Composition.section:vital_signs_section.entry:vital_signs_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

goals_section

S C

0..1

Element id

Composition.section:goals_section

Short description

Goals Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:goals_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:goals_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:goals_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:goals_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:goals_section.code

Short description

Goals

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "61146-7"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:goals_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:goals_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:goals_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:goals_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:goals_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:goals_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

goals_entry

S C

0..*

Element id

Composition.section:goals_section.entry:goals_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:goals_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:goals_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

health_concerns_section

S C

0..1

Element id

Composition.section:health_concerns_section

Short description

Health Concerns Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:health_concerns_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:health_concerns_section.code

Short description

Health concerns section code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "75310-3"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:health_concerns_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:health_concerns_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

health_concerns_entry

S C

0..*

Element id

Composition.section:health_concerns_section.entry:health_concerns_entry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

Hybrid View

DischargeSummaryOCRE (Composition)

There are no (further) constraints on this element

Element id

Composition

Short description

A set of resources composed into a single coherent clinical statement with clinical attestation

Definition

Comments

Data type

Constraints

dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty()
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-6: A resource should have narrative for robust management
text.`div`.exists()
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty()

Mappings

rim: Entity. Role, or Act
workflow: Event
rim: Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
cda: ClinicalDocument
fhirdocumentreference: when described by DocumentReference

0..1

There are no (further) constraints on this element

Element id

Composition.id

Short description

Logical id of this artifact

Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

There are no (further) constraints on this element

Element id

Composition.meta

Short description

Metadata about the resource

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A

implicitRules

Σ ?!

0..1

There are no (further) constraints on this element

Element id

Composition.implicitRules

Short description

A set of rules under which this content was created

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

language

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.language

Short description

Language of the resource content

Definition

The base language in which the resource is written.

Comments

Data type

Binding

A human language.

CommonLanguages (preferred)

Binding extensions

MaxValueSet	AllLanguages

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

text

0..1

There are no (further) constraints on this element

Element id

Composition.text

Short description

Text summary of the resource, for human interpretation

Alternate names

narrative, html, xhtml, display

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: Act.text?

contained

0..*

There are no (further) constraints on this element

Element id

Composition.contained

Short description

Contained, inline Resources

Alternate names

inline resources, anonymous resources, contained resources

Definition

Comments

Data type

Mappings

rim: Entity. Role, or Act
rim: N/A

extension

0..*

There are no (further) constraints on this element

Element id

Composition.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

versionNumber

0..1

There are no (further) constraints on this element

Element id

Composition.extension:versionNumber

Short description

Version-specific identifier for composition

Alternate names

extensions, user content

Definition

Version specific identifier for the composition, assigned when each version is created/updated.

Comments

Data type

Extension URL

CDVersionNumber

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

?! C

0..*

There are no (further) constraints on this element

Element id

Composition.modifierExtension

Short description

Extensions that cannot be ignored

Alternate names

extensions, user content

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

identifier

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.identifier

Short description

identifier

Definition

A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.

Comments

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
servd: Identifier
workflow: Event.identifier
w5: FiveWs.identifier
rim: Document.id / Document.setId
cda: .setId
fhirdocumentreference: DocumentReference.masterIdentifier

status

Σ ?!

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.status

Short description

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.

Requirements

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Comments

Data type

Binding

The workflow/clinical status of the composition.

CompositionStatus (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.status
w5: FiveWs.status
rim: interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
cda: n/a
fhirdocumentreference: DocumentReference.status

type

S Σ

1..1

CodeableConceptBinding

Element id

Composition.type

Short description

Discharge Summary

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.

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.

Data type

DischargeSummaryDocumentTypeCode (required)

Binding

Type of a composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
workflow: Event.code
w5: FiveWs.class
rim: ./code
cda: .code
fhirdocumentreference: DocumentReference.type

category

0..*

There are no (further) constraints on this element

Element id

Composition.category

Short description

Categorization of Composition

Definition

A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

Requirements

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Comments

This is a metadata field from XDS/MHD.

Data type

DocumentClassValueSet (example)

Binding

High-level kind of a clinical document at a macro level.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
workflow: Event.subject
w5: FiveWs.class
rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
cda: n/a
fhirdocumentreference: DocumenttReference.category

subject

S Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.subject

Short description

Who and/or what the composition is about

Definition

Requirements

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

Comments

For clinical documents, this is usually the patient.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.subject[x]
rim: .participation[typeCode="SBJ"].role[typeCode="PAT"]
cda: .recordTarget
fhirdocumentreference: DocumentReference.subject
w5: FiveWs.subject

encounter

S Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.encounter

Short description

Context of the Composition

Definition

Describes the clinical encounter or type of care this documentation is associated with.

Requirements

Provides context for the composition and supports searching.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.context
w5: FiveWs.context
rim: unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
cda: .componentOf.encompassingEncounter
fhirdocumentreference: DocumentReference.context.encounter

date

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.date

Short description

date

Definition

The composition editing time, when the composition was last logically changed by the author.

Requirements

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Comments

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.occurrence[x]
w5: FiveWs.done[x]
rim: .effectiveTime[type="TS"]
cda: .effectiveTime
fhirdocumentreference: DocumentReference.content.attachment.date, DocumentReference.created

author

S Σ C

1..*

Reference(Device | RelatedPerson | PatientEHR | PractitionerEHR | PractitionerRoleEHR)

There are no (further) constraints on this element

Element id

Composition.author

Short description

Who and/or what authored the composition

Definition

Identifies who is responsible for the information in the composition, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Reference(Device | RelatedPerson | PatientEHR | PractitionerEHR | PractitionerRoleEHR)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor
fhirdocumentreference: DocumentReference.agent

title

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.title

Short description

Document Title

Definition

Official human-readable label for the composition.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title
fhirdocumentreference: DocumentReference.description, DocumentReference.content.attachment.title

confidentiality

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.confidentiality

Short description

Use the confidentiality codes in Meta.security

Definition

Use the confidentiality codes in Meta.security (https://hl7.org/fhir/security-labels.html)

Comments

Data type

v3.ConfidentialityClassification (required)

Binding

Codes specifying the level of confidentiality of the composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .confidentialityCode
cda: .confidentialityCode
fhirdocumentreference: DocumentReference.securityLabel

attester

0..*

There are no (further) constraints on this element

Element id

Composition.attester

Short description

Attests to accuracy of composition

Definition

A participant who has attested to the accuracy of the composition/document.

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Data type

Slicing

Unordered, Open, by mode(Value)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

(All Slices)

The requirements in this element apply to all slices

0..1

There are no (further) constraints on this element

Element id

Composition.attester.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

mode

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.attester.mode

Short description

personal | professional | legal | official

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The way in which a person authenticated a composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

There are no (further) constraints on this element

Element id

Composition.attester.time

Short description

When the composition was attested

Definition

When the composition was attested by the party.

Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

0..1

Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)

There are no (further) constraints on this element

Element id

Composition.attester.party

Short description

Who attested the composition

Definition

Who attested the composition in the specified way.

Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Comments

Data type

Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.witness
rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
cda: .authenticator.assignedEnttty

legal_attester

0..1

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester

Short description

attester

Definition

A participant who has attested to the accuracy of the composition/document.

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

0..1

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

mode

1..1

codeBindingFixed Value

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.mode

Short description

mode

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The way in which a person authenticated a composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Fixed value

legal

Mappings

rim: n/a
rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.time

Short description

When the composition was attested

Definition

When the composition was attested by the party.

Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

S C

1..1

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.party

Short description

party

Definition

Who attested the composition in the specified way.

Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.witness
rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
cda: .authenticator.assignedEnttty

professional_attester

0..*

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester

Short description

attester

Definition

A participant who has attested to the accuracy of the composition/document.

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

0..1

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

mode

1..1

codeBindingFixed Value

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.mode

Short description

mode

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The way in which a person authenticated a composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Fixed value

professional

Mappings

rim: n/a
rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.time

Short description

When the composition was attested

Definition

When the composition was attested by the party.

Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

S C

1..1

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.party

Short description

party

Definition

Who attested the composition in the specified way.

Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.witness
rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
cda: .authenticator.assignedEnttty

personal_attester

0..*

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester

Short description

attester

Definition

A participant who has attested to the accuracy of the composition/document.

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

0..1

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

mode

1..1

codeBindingFixed Value

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.mode

Short description

mode

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The way in which a person authenticated a composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Fixed value

personal

Mappings

rim: n/a
rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.time

Short description

When the composition was attested

Definition

When the composition was attested by the party.

Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

S C

1..1

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.party

Short description

party

Definition

Who attested the composition in the specified way.

Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.witness
rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
cda: .authenticator.assignedEnttty

custodian

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.custodian

Short description

Organization which maintains the composition

Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.

Requirements

Identifies where to go to find the current version, where to report issues, etc.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
cda: .custodian.assignedCustodian
fhirdocumentreference: DocumentReference.custodian

relatesTo

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo

Short description

Relationships to other compositions/documents

Definition

Relationships that this composition has with other compositions or documents that already exist.

Comments

A document is a version specific composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .outboundRelationship
cda: .relatedDocument
fhirdocumentreference: DocumentReference.relatesTo

0..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

code

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.relatesTo.code

Short description

replaces | transforms | signs | appends

Definition

The type of relationship that this composition has with anther composition or document.

Comments

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

Data type

DocumentRelationshipType (required)

Binding

The type of relationship between documents.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .outboundRelationship.typeCode
cda: .relatedDocument.typeCode
fhirdocumentreference: DocumentReference.relatesTo.code

target[x]

1..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.target[x]

Short description

Target of the relationship

Definition

The target composition/document of this relationship.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .target[classCode="DOC", moodCode="EVN"].id
cda: .relatedDocument.id
fhirdocumentreference: DocumentReference.relatesTo.target

targetIdentifier

There are no (further) constraints on this element

Data type

targetReference

There are no (further) constraints on this element

Data type

event

0..*

There are no (further) constraints on this element

Element id

Composition.event

Short description

The clinical service(s) being documented

Definition

The clinical service, such as a colonoscopy or an appendectomy, being documented.

Requirements

Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.

Comments

The event needs to be consistent with the type element, though can provide further information if desired.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
cda: .documentationOf.serviceEvent
fhirdocumentreference: DocumentReference.event

0..1

There are no (further) constraints on this element

Element id

Composition.event.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.event.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

code

0..*

There are no (further) constraints on this element

Element id

Composition.event.code

Short description

Code(s) that apply to the event being documented

Definition

Comments

Data type

Binding

This list of codes represents the main clinical acts being documented.

ActCode (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .code
cda: .code
fhirdocumentreference: DocumentReference.event.code

period

Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.event.period

Short description

The period covered by the documentation

Definition

The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.

Comments

Period is not used for a duration (a measure of elapsed time). See Duration.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
per-1: If present, start SHALL have a lower value than end
start.hasValue().not() or end.hasValue().not() or (start <= end)

Mappings

rim: n/a
v2: DR
rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
rim: .effectiveTime
cda: .effectiveTime
fhirdocumentreference: DocumentReference.event.period

detail

Σ C

0..*

There are no (further) constraints on this element

Element id

Composition.event.detail

Short description

The event(s) being documented

Definition

The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode="SUBJ"].target
cda: n/a

section

3..*

Element id

Composition.section

Short description

Composition is broken into sections

Definition

The root of the sections that make up the composition.

Data type

Slicing

Unordered, Open, by code(Value)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

(All Slices)

The requirements in this element apply to all slices

0..1

There are no (further) constraints on this element

Element id

Composition.section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

0..1

There are no (further) constraints on this element

Element id

Composition.section.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

0..1

There are no (further) constraints on this element

Element id

Composition.section.code

Short description

Classification of section (recommended)

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

0..1

There are no (further) constraints on this element

Element id

Composition.section.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

allergies_and_intolerances_section

S C

1..1

Element id

Composition.section:allergies_and_intolerances_section

Short description

Allergies and Intolerances Section

Definition

The root of the sections that make up the composition.

Comments

Allergies and Intolerances Section

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:allergies_and_intolerances_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:allergies_and_intolerances_section.code

Short description

Allergies and adverse reactions

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "48765-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:allergies_and_intolerances_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:allergies_and_intolerances_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

allergy_entry

S C

0..*

Element id

Composition.section:allergies_and_intolerances_section.entry:allergy_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

hospital_course_section

S C

1..1

Element id

Composition.section:hospital_course_section

Short description

Hospital Course Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_course_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_course_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "8648-8"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_course_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

discharge_diagnosis_section

S C

1..1

Element id

Composition.section:discharge_diagnosis_section

Short description

Discharge Diagnosis Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:discharge_diagnosis_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:discharge_diagnosis_section.code

Short description

Hospital discharge diagnosis

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11535-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:discharge_diagnosis_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:discharge_diagnosis_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

discharge_diagnosis_entry

S C

0..*

Element id

Composition.section:discharge_diagnosis_section.entry:discharge_diagnosis_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

plan_of_treatment_section

S C

0..1

Element id

Composition.section:plan_of_treatment_section

Short description

Plan of Treatment Section

Definition

The root of the sections that make up the composition.

Comments

Plan of Treatment Section

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:plan_of_treatment_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:plan_of_treatment_section.code

Short description

Plan of treatment

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "18776-5"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:plan_of_treatment_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:plan_of_treatment_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

sliceEntry

0..*

Element id

Composition.section:plan_of_treatment_section.entry:sliceEntry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

discharge_medications_section

S C

0..1

Element id

Composition.section:discharge_medications_section

Short description

Discharge Medications Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:discharge_medications_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:discharge_medications_section.code

Short description

Hospital discharge medications

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10183-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:discharge_medications_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:discharge_medications_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

discharge_medications_entry

S C

0..*

Reference(Medication | MedicationRequest | MedicationStatement)

Element id

Composition.section:discharge_medications_section.entry:discharge_medications_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Reference(Medication | MedicationRequest | MedicationStatement)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

admission_diagnosis_section

S C

0..1

Element id

Composition.section:admission_diagnosis_section

Short description

Admission Diagnosis Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:admission_diagnosis_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:admission_diagnosis_section.code

Short description

Hospital admission diagnosis

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "46241-6"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:admission_diagnosis_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:admission_diagnosis_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

admission_diagnosis_entry

S C

0..*

Element id

Composition.section:admission_diagnosis_section.entry:admission_diagnosis_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

admission_medications_section

S C

0..1

Element id

Composition.section:admission_medications_section

Short description

Admission Medications Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:admission_medications_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:admission_medications_section.code

Short description

Medications on admission

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "42346-7"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:admission_medications_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:admission_medications_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

admission_medications_entry

S C

0..*

Reference(Medication | MedicationRequest | MedicationStatement)

Element id

Composition.section:admission_medications_section.entry:admission_medications_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Reference(Medication | MedicationRequest | MedicationStatement)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

chief_complaint_and_reason_for_visit_section

S C

0..1

Element id

Composition.section:chief_complaint_and_reason_for_visit_section

Short description

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "46239-0"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

chief_complaint_section

S C

0..1

Element id

Composition.section:chief_complaint_section

Short description

Chief Complaint Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:chief_complaint_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:chief_complaint_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10154-3"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:chief_complaint_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

family_history_section

S C

0..1

Element id

Composition.section:family_history_section

Short description

Family History Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:family_history_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:family_history_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10157-6"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:family_history_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:family_history_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

family_history_entry

S C

0..*

Element id

Composition.section:family_history_section.entry:family_history_entry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

functional_status_section

S C

0..1

Element id

Composition.section:functional_status_section

Short description

Functional Status Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:functional_status_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:functional_status_section.code

Short description

Functional status

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "47420-5"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:functional_status_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:functional_status_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

functional_status_entry

S C

0..*

Reference(ClinicalImpression | Observation | ConditionEHR)

Element id

Composition.section:functional_status_section.entry:functional_status_entry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Reference(ClinicalImpression | Observation | ConditionEHR)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

history_of_present_illness_section

S C

0..1

Element id

Composition.section:history_of_present_illness_section

Short description

History of Present Illness Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:history_of_present_illness_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:history_of_present_illness_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10164-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:history_of_present_illness_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

hospital_consultations_section

S C

0..1

Element id

Composition.section:hospital_consultations_section

Short description

Hospital Consultations Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_consultations_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_consultations_section.code

Short description

Hospital consultations

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "18841-7"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_consultations_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

hospital_discharge_instructions_section

S C

0..1

Element id

Composition.section:hospital_discharge_instructions_section

Short description

Hospital Discharge Instructions Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_discharge_instructions_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_discharge_instructions_section.code

Short description

Hospital discharge instructions

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "8653-8"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_discharge_instructions_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

hospital_discharge_physical_section

S C

0..1

Element id

Composition.section:hospital_discharge_physical_section

Short description

Hospital Discharge Physical Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_discharge_physical_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_discharge_physical_section.code

Short description

Hospital discharge physical

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10184-0"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_discharge_physical_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

hospital_discharge_studies_section

S C

0..1

Element id

Composition.section:hospital_discharge_studies_section

Short description

Hospital Discharge Studies Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_discharge_studies_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_discharge_studies_section.code

Short description

Hospital discharge studies summary

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11493-4"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_discharge_studies_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

immunizations_section

S C

0..1

Element id

Composition.section:immunizations_section

Short description

Immunizations Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:immunizations_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:immunizations_section.code

Short description

Immunizations

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11369-6"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:immunizations_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:immunizations_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

immunizations_entry

S C

0..*

Element id

Composition.section:immunizations_section.entry:immunizations_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

nutrition_section

S C

0..1

Element id

Composition.section:nutrition_section

Short description

Nutrition Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:nutrition_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:nutrition_section.code

Short description

Diet and nutrition

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "61144-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:nutrition_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:nutrition_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

nutrition_entry

S C

0..*

Element id

Composition.section:nutrition_section.entry:nutrition_entry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

past_medical_history_section

S C

0..1

Element id

Composition.section:past_medical_history_section

Short description

Past Medical History Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:past_medical_history_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:past_medical_history_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11348-0"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:past_medical_history_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:past_medical_history_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

past_medical_history_entry

S C

0..*

Element id

Composition.section:past_medical_history_section.entry:past_medical_history_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

problem_section

S C

0..1

Element id

Composition.section:problem_section

Short description

Problem Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:problem_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:problem_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:problem_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:problem_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:problem_section.code

Short description

Problem list

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11450-4"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:problem_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:problem_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:problem_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:problem_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:problem_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:problem_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

problem_entry

S C

0..*

Element id

Composition.section:problem_section.entry:problem_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:problem_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:problem_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

procedures_section

S C

0..1

Element id

Composition.section:procedures_section

Short description

Procedures Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:procedures_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:procedures_section.code

Short description

History of procedures

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "47519-4"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:procedures_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:procedures_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

procedure_entry

S C

0..*

Element id

Composition.section:procedures_section.entry:procedure_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

reason_for_visit_section

S C

0..1

Element id

Composition.section:reason_for_visit_section

Short description

Reason for Visit Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:reason_for_visit_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:reason_for_visit_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "29299-5"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:reason_for_visit_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

review_of_systems_section

S C

0..1

Element id

Composition.section:review_of_systems_section

Short description

Review of Systems Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:review_of_systems_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:review_of_systems_section.code

Short description

Review of systems

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10187-3"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:review_of_systems_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

social_history_section

S C

0..1

Element id

Composition.section:social_history_section

Short description

Social History Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:social_history_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:social_history_section.code

Short description

Social history

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "29762-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:social_history_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:social_history_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

smoking_status_entry

S C

0..*

Element id

Composition.section:social_history_section.entry:smoking_status_entry

Short description

Smoking status

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

vital_signs_section

S C

0..1

Element id

Composition.section:vital_signs_section

Short description

Vital Signs Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:vital_signs_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:vital_signs_section.code

Short description

Vital signs

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "8716-3"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:vital_signs_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:vital_signs_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

vital_signs_entry

S C

0..*

Element id

Composition.section:vital_signs_section.entry:vital_signs_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

goals_section

S C

0..1

Element id

Composition.section:goals_section

Short description

Goals Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:goals_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:goals_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:goals_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:goals_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:goals_section.code

Short description

Goals

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "61146-7"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:goals_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:goals_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:goals_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:goals_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:goals_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:goals_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

goals_entry

S C

0..*

Element id

Composition.section:goals_section.entry:goals_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:goals_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:goals_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

health_concerns_section

S C

0..1

Element id

Composition.section:health_concerns_section

Short description

Health Concerns Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:health_concerns_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:health_concerns_section.code

Short description

Health concerns section code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "75310-3"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:health_concerns_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:health_concerns_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

health_concerns_entry

S C

0..*

Element id

Composition.section:health_concerns_section.entry:health_concerns_entry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

Snapshot View

DischargeSummaryOCRE (Composition)

There are no (further) constraints on this element

Element id

Composition

Short description

A set of resources composed into a single coherent clinical statement with clinical attestation

Definition

Comments

Data type

Constraints

dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty()
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-6: A resource should have narrative for robust management
text.`div`.exists()
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty()

Mappings

rim: Entity. Role, or Act
workflow: Event
rim: Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
cda: ClinicalDocument
fhirdocumentreference: when described by DocumentReference

0..1

There are no (further) constraints on this element

Element id

Composition.id

Short description

Logical id of this artifact

Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

There are no (further) constraints on this element

Element id

Composition.meta

Short description

Metadata about the resource

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A

implicitRules

Σ ?!

0..1

There are no (further) constraints on this element

Element id

Composition.implicitRules

Short description

A set of rules under which this content was created

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

language

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.language

Short description

Language of the resource content

Definition

The base language in which the resource is written.

Comments

Data type

Binding

A human language.

CommonLanguages (preferred)

Binding extensions

MaxValueSet	AllLanguages

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

text

0..1

There are no (further) constraints on this element

Element id

Composition.text

Short description

Text summary of the resource, for human interpretation

Alternate names

narrative, html, xhtml, display

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: Act.text?

contained

0..*

There are no (further) constraints on this element

Element id

Composition.contained

Short description

Contained, inline Resources

Alternate names

inline resources, anonymous resources, contained resources

Definition

Comments

Data type

Mappings

rim: Entity. Role, or Act
rim: N/A

extension

0..*

There are no (further) constraints on this element

Element id

Composition.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

versionNumber

0..1

There are no (further) constraints on this element

Element id

Composition.extension:versionNumber

Short description

Version-specific identifier for composition

Alternate names

extensions, user content

Definition

Version specific identifier for the composition, assigned when each version is created/updated.

Comments

Data type

Extension URL

CDVersionNumber

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

?! C

0..*

There are no (further) constraints on this element

Element id

Composition.modifierExtension

Short description

Extensions that cannot be ignored

Alternate names

extensions, user content

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

identifier

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.identifier

Short description

identifier

Definition

A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.

Comments

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
servd: Identifier
workflow: Event.identifier
w5: FiveWs.identifier
rim: Document.id / Document.setId
cda: .setId
fhirdocumentreference: DocumentReference.masterIdentifier

status

Σ ?!

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.status

Short description

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.

Requirements

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Comments

Data type

Binding

The workflow/clinical status of the composition.

CompositionStatus (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.status
w5: FiveWs.status
rim: interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
cda: n/a
fhirdocumentreference: DocumentReference.status

type

S Σ

1..1

CodeableConceptBinding

Element id

Composition.type

Short description

Discharge Summary

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.

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.

Data type

DischargeSummaryDocumentTypeCode (required)

Binding

Type of a composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
workflow: Event.code
w5: FiveWs.class
rim: ./code
cda: .code
fhirdocumentreference: DocumentReference.type

category

0..*

There are no (further) constraints on this element

Element id

Composition.category

Short description

Categorization of Composition

Definition

A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

Requirements

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Comments

This is a metadata field from XDS/MHD.

Data type

DocumentClassValueSet (example)

Binding

High-level kind of a clinical document at a macro level.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
workflow: Event.subject
w5: FiveWs.class
rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
cda: n/a
fhirdocumentreference: DocumenttReference.category

subject

S Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.subject

Short description

Who and/or what the composition is about

Definition

Requirements

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

Comments

For clinical documents, this is usually the patient.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.subject[x]
rim: .participation[typeCode="SBJ"].role[typeCode="PAT"]
cda: .recordTarget
fhirdocumentreference: DocumentReference.subject
w5: FiveWs.subject

encounter

S Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.encounter

Short description

Context of the Composition

Definition

Describes the clinical encounter or type of care this documentation is associated with.

Requirements

Provides context for the composition and supports searching.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.context
w5: FiveWs.context
rim: unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
cda: .componentOf.encompassingEncounter
fhirdocumentreference: DocumentReference.context.encounter

date

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.date

Short description

date

Definition

The composition editing time, when the composition was last logically changed by the author.

Requirements

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Comments

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.occurrence[x]
w5: FiveWs.done[x]
rim: .effectiveTime[type="TS"]
cda: .effectiveTime
fhirdocumentreference: DocumentReference.content.attachment.date, DocumentReference.created

author

S Σ C

1..*

Reference(Device | RelatedPerson | PatientEHR | PractitionerEHR | PractitionerRoleEHR)

There are no (further) constraints on this element

Element id

Composition.author

Short description

Who and/or what authored the composition

Definition

Identifies who is responsible for the information in the composition, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Reference(Device | RelatedPerson | PatientEHR | PractitionerEHR | PractitionerRoleEHR)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor
fhirdocumentreference: DocumentReference.agent

title

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.title

Short description

Document Title

Definition

Official human-readable label for the composition.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title
fhirdocumentreference: DocumentReference.description, DocumentReference.content.attachment.title

confidentiality

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.confidentiality

Short description

Use the confidentiality codes in Meta.security

Definition

Use the confidentiality codes in Meta.security (https://hl7.org/fhir/security-labels.html)

Comments

Data type

v3.ConfidentialityClassification (required)

Binding

Codes specifying the level of confidentiality of the composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .confidentialityCode
cda: .confidentialityCode
fhirdocumentreference: DocumentReference.securityLabel

attester

0..*

There are no (further) constraints on this element

Element id

Composition.attester

Short description

Attests to accuracy of composition

Definition

A participant who has attested to the accuracy of the composition/document.

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Data type

Slicing

Unordered, Open, by mode(Value)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

(All Slices)

The requirements in this element apply to all slices

0..1

There are no (further) constraints on this element

Element id

Composition.attester.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

mode

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.attester.mode

Short description

personal | professional | legal | official

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The way in which a person authenticated a composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

There are no (further) constraints on this element

Element id

Composition.attester.time

Short description

When the composition was attested

Definition

When the composition was attested by the party.

Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

0..1

Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)

There are no (further) constraints on this element

Element id

Composition.attester.party

Short description

Who attested the composition

Definition

Who attested the composition in the specified way.

Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Comments

Data type

Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.witness
rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
cda: .authenticator.assignedEnttty

legal_attester

0..1

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester

Short description

attester

Definition

A participant who has attested to the accuracy of the composition/document.

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

0..1

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

mode

1..1

codeBindingFixed Value

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.mode

Short description

mode

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The way in which a person authenticated a composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Fixed value

legal

Mappings

rim: n/a
rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.time

Short description

When the composition was attested

Definition

When the composition was attested by the party.

Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

S C

1..1

There are no (further) constraints on this element

Element id

Composition.attester:legal_attester.party

Short description

party

Definition

Who attested the composition in the specified way.

Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.witness
rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
cda: .authenticator.assignedEnttty

professional_attester

0..*

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester

Short description

attester

Definition

A participant who has attested to the accuracy of the composition/document.

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

0..1

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

mode

1..1

codeBindingFixed Value

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.mode

Short description

mode

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The way in which a person authenticated a composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Fixed value

professional

Mappings

rim: n/a
rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.time

Short description

When the composition was attested

Definition

When the composition was attested by the party.

Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

S C

1..1

There are no (further) constraints on this element

Element id

Composition.attester:professional_attester.party

Short description

party

Definition

Who attested the composition in the specified way.

Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.witness
rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
cda: .authenticator.assignedEnttty

personal_attester

0..*

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester

Short description

attester

Definition

A participant who has attested to the accuracy of the composition/document.

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

0..1

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

mode

1..1

codeBindingFixed Value

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.mode

Short description

mode

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The way in which a person authenticated a composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Fixed value

personal

Mappings

rim: n/a
rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.time

Short description

When the composition was attested

Definition

When the composition was attested by the party.

Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

S C

1..1

There are no (further) constraints on this element

Element id

Composition.attester:personal_attester.party

Short description

party

Definition

Who attested the composition in the specified way.

Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.witness
rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
cda: .authenticator.assignedEnttty

custodian

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.custodian

Short description

Organization which maintains the composition

Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.

Requirements

Identifies where to go to find the current version, where to report issues, etc.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
cda: .custodian.assignedCustodian
fhirdocumentreference: DocumentReference.custodian

relatesTo

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo

Short description

Relationships to other compositions/documents

Definition

Relationships that this composition has with other compositions or documents that already exist.

Comments

A document is a version specific composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .outboundRelationship
cda: .relatedDocument
fhirdocumentreference: DocumentReference.relatesTo

0..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

code

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.relatesTo.code

Short description

replaces | transforms | signs | appends

Definition

The type of relationship that this composition has with anther composition or document.

Comments

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

Data type

DocumentRelationshipType (required)

Binding

The type of relationship between documents.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .outboundRelationship.typeCode
cda: .relatedDocument.typeCode
fhirdocumentreference: DocumentReference.relatesTo.code

target[x]

1..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.target[x]

Short description

Target of the relationship

Definition

The target composition/document of this relationship.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .target[classCode="DOC", moodCode="EVN"].id
cda: .relatedDocument.id
fhirdocumentreference: DocumentReference.relatesTo.target

targetIdentifier

There are no (further) constraints on this element

Data type

targetReference

There are no (further) constraints on this element

Data type

event

0..*

There are no (further) constraints on this element

Element id

Composition.event

Short description

The clinical service(s) being documented

Definition

The clinical service, such as a colonoscopy or an appendectomy, being documented.

Requirements

Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.

Comments

The event needs to be consistent with the type element, though can provide further information if desired.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
cda: .documentationOf.serviceEvent
fhirdocumentreference: DocumentReference.event

0..1

There are no (further) constraints on this element

Element id

Composition.event.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.event.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

code

0..*

There are no (further) constraints on this element

Element id

Composition.event.code

Short description

Code(s) that apply to the event being documented

Definition

Comments

Data type

Binding

This list of codes represents the main clinical acts being documented.

ActCode (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .code
cda: .code
fhirdocumentreference: DocumentReference.event.code

period

Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.event.period

Short description

The period covered by the documentation

Definition

The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.

Comments

Period is not used for a duration (a measure of elapsed time). See Duration.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
per-1: If present, start SHALL have a lower value than end
start.hasValue().not() or end.hasValue().not() or (start <= end)

Mappings

rim: n/a
v2: DR
rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
rim: .effectiveTime
cda: .effectiveTime
fhirdocumentreference: DocumentReference.event.period

detail

Σ C

0..*

There are no (further) constraints on this element

Element id

Composition.event.detail

Short description

The event(s) being documented

Definition

The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode="SUBJ"].target
cda: n/a

section

3..*

Element id

Composition.section

Short description

Composition is broken into sections

Definition

The root of the sections that make up the composition.

Data type

Slicing

Unordered, Open, by code(Value)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

(All Slices)

The requirements in this element apply to all slices

0..1

There are no (further) constraints on this element

Element id

Composition.section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

0..1

There are no (further) constraints on this element

Element id

Composition.section.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

0..1

There are no (further) constraints on this element

Element id

Composition.section.code

Short description

Classification of section (recommended)

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

0..1

There are no (further) constraints on this element

Element id

Composition.section.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

allergies_and_intolerances_section

S C

1..1

Element id

Composition.section:allergies_and_intolerances_section

Short description

Allergies and Intolerances Section

Definition

The root of the sections that make up the composition.

Comments

Allergies and Intolerances Section

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:allergies_and_intolerances_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:allergies_and_intolerances_section.code

Short description

Allergies and adverse reactions

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "48765-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:allergies_and_intolerances_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:allergies_and_intolerances_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

allergy_entry

S C

0..*

Element id

Composition.section:allergies_and_intolerances_section.entry:allergy_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:allergies_and_intolerances_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

hospital_course_section

S C

1..1

Element id

Composition.section:hospital_course_section

Short description

Hospital Course Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_course_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_course_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "8648-8"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_course_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_course_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

discharge_diagnosis_section

S C

1..1

Element id

Composition.section:discharge_diagnosis_section

Short description

Discharge Diagnosis Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:discharge_diagnosis_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:discharge_diagnosis_section.code

Short description

Hospital discharge diagnosis

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11535-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:discharge_diagnosis_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:discharge_diagnosis_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

discharge_diagnosis_entry

S C

0..*

Element id

Composition.section:discharge_diagnosis_section.entry:discharge_diagnosis_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:discharge_diagnosis_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

plan_of_treatment_section

S C

0..1

Element id

Composition.section:plan_of_treatment_section

Short description

Plan of Treatment Section

Definition

The root of the sections that make up the composition.

Comments

Plan of Treatment Section

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:plan_of_treatment_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:plan_of_treatment_section.code

Short description

Plan of treatment

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "18776-5"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:plan_of_treatment_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:plan_of_treatment_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

sliceEntry

0..*

Element id

Composition.section:plan_of_treatment_section.entry:sliceEntry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:plan_of_treatment_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

discharge_medications_section

S C

0..1

Element id

Composition.section:discharge_medications_section

Short description

Discharge Medications Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:discharge_medications_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:discharge_medications_section.code

Short description

Hospital discharge medications

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10183-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:discharge_medications_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:discharge_medications_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

discharge_medications_entry

S C

0..*

Reference(Medication | MedicationRequest | MedicationStatement)

Element id

Composition.section:discharge_medications_section.entry:discharge_medications_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Reference(Medication | MedicationRequest | MedicationStatement)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:discharge_medications_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

admission_diagnosis_section

S C

0..1

Element id

Composition.section:admission_diagnosis_section

Short description

Admission Diagnosis Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:admission_diagnosis_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:admission_diagnosis_section.code

Short description

Hospital admission diagnosis

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "46241-6"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:admission_diagnosis_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:admission_diagnosis_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

admission_diagnosis_entry

S C

0..*

Element id

Composition.section:admission_diagnosis_section.entry:admission_diagnosis_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:admission_diagnosis_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

admission_medications_section

S C

0..1

Element id

Composition.section:admission_medications_section

Short description

Admission Medications Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:admission_medications_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:admission_medications_section.code

Short description

Medications on admission

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "42346-7"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:admission_medications_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:admission_medications_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

admission_medications_entry

S C

0..*

Reference(Medication | MedicationRequest | MedicationStatement)

Element id

Composition.section:admission_medications_section.entry:admission_medications_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Reference(Medication | MedicationRequest | MedicationStatement)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:admission_medications_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

chief_complaint_and_reason_for_visit_section

S C

0..1

Element id

Composition.section:chief_complaint_and_reason_for_visit_section

Short description

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "46239-0"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_and_reason_for_visit_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

chief_complaint_section

S C

0..1

Element id

Composition.section:chief_complaint_section

Short description

Chief Complaint Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:chief_complaint_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:chief_complaint_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10154-3"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:chief_complaint_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:chief_complaint_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

family_history_section

S C

0..1

Element id

Composition.section:family_history_section

Short description

Family History Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:family_history_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:family_history_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10157-6"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:family_history_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:family_history_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

family_history_entry

S C

0..*

Element id

Composition.section:family_history_section.entry:family_history_entry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:family_history_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

functional_status_section

S C

0..1

Element id

Composition.section:functional_status_section

Short description

Functional Status Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:functional_status_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:functional_status_section.code

Short description

Functional status

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "47420-5"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:functional_status_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:functional_status_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

functional_status_entry

S C

0..*

Reference(ClinicalImpression | Observation | ConditionEHR)

Element id

Composition.section:functional_status_section.entry:functional_status_entry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Reference(ClinicalImpression | Observation | ConditionEHR)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:functional_status_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

history_of_present_illness_section

S C

0..1

Element id

Composition.section:history_of_present_illness_section

Short description

History of Present Illness Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:history_of_present_illness_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:history_of_present_illness_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10164-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:history_of_present_illness_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:history_of_present_illness_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

hospital_consultations_section

S C

0..1

Element id

Composition.section:hospital_consultations_section

Short description

Hospital Consultations Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_consultations_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_consultations_section.code

Short description

Hospital consultations

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "18841-7"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_consultations_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_consultations_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

hospital_discharge_instructions_section

S C

0..1

Element id

Composition.section:hospital_discharge_instructions_section

Short description

Hospital Discharge Instructions Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_discharge_instructions_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_discharge_instructions_section.code

Short description

Hospital discharge instructions

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "8653-8"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_discharge_instructions_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_instructions_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

hospital_discharge_physical_section

S C

0..1

Element id

Composition.section:hospital_discharge_physical_section

Short description

Hospital Discharge Physical Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_discharge_physical_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_discharge_physical_section.code

Short description

Hospital discharge physical

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10184-0"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_discharge_physical_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_physical_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

hospital_discharge_studies_section

S C

0..1

Element id

Composition.section:hospital_discharge_studies_section

Short description

Hospital Discharge Studies Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:hospital_discharge_studies_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:hospital_discharge_studies_section.code

Short description

Hospital discharge studies summary

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11493-4"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:hospital_discharge_studies_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:hospital_discharge_studies_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

immunizations_section

S C

0..1

Element id

Composition.section:immunizations_section

Short description

Immunizations Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:immunizations_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:immunizations_section.code

Short description

Immunizations

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11369-6"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:immunizations_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:immunizations_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

immunizations_entry

S C

0..*

Element id

Composition.section:immunizations_section.entry:immunizations_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:immunizations_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

nutrition_section

S C

0..1

Element id

Composition.section:nutrition_section

Short description

Nutrition Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:nutrition_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:nutrition_section.code

Short description

Diet and nutrition

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "61144-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:nutrition_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:nutrition_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

nutrition_entry

S C

0..*

Element id

Composition.section:nutrition_section.entry:nutrition_entry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:nutrition_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

past_medical_history_section

S C

0..1

Element id

Composition.section:past_medical_history_section

Short description

Past Medical History Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:past_medical_history_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:past_medical_history_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11348-0"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:past_medical_history_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:past_medical_history_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

past_medical_history_entry

S C

0..*

Element id

Composition.section:past_medical_history_section.entry:past_medical_history_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:past_medical_history_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

problem_section

S C

0..1

Element id

Composition.section:problem_section

Short description

Problem Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:problem_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:problem_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:problem_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:problem_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:problem_section.code

Short description

Problem list

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "11450-4"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:problem_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:problem_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:problem_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:problem_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:problem_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:problem_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

problem_entry

S C

0..*

Element id

Composition.section:problem_section.entry:problem_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:problem_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:problem_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

procedures_section

S C

0..1

Element id

Composition.section:procedures_section

Short description

Procedures Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:procedures_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:procedures_section.code

Short description

History of procedures

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "47519-4"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:procedures_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:procedures_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

procedure_entry

S C

0..*

Element id

Composition.section:procedures_section.entry:procedure_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:procedures_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

reason_for_visit_section

S C

0..1

Element id

Composition.section:reason_for_visit_section

Short description

Reason for Visit Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:reason_for_visit_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:reason_for_visit_section.code

Short description

code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "29299-5"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:reason_for_visit_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:reason_for_visit_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

review_of_systems_section

S C

0..1

Element id

Composition.section:review_of_systems_section

Short description

Review of Systems Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:review_of_systems_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:review_of_systems_section.code

Short description

Review of systems

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "10187-3"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:review_of_systems_section.text

Short description

This section contains only human readable content

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:review_of_systems_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

social_history_section

S C

0..1

Element id

Composition.section:social_history_section

Short description

Social History Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:social_history_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:social_history_section.code

Short description

Social history

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "29762-2"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:social_history_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:social_history_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

smoking_status_entry

S C

0..*

Element id

Composition.section:social_history_section.entry:smoking_status_entry

Short description

Smoking status

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:social_history_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

vital_signs_section

S C

0..1

Element id

Composition.section:vital_signs_section

Short description

Vital Signs Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:vital_signs_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:vital_signs_section.code

Short description

Vital signs

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "8716-3"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:vital_signs_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:vital_signs_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

vital_signs_entry

S C

0..*

Element id

Composition.section:vital_signs_section.entry:vital_signs_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:vital_signs_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

goals_section

S C

0..1

Element id

Composition.section:goals_section

Short description

Goals Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:goals_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:goals_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:goals_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:goals_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:goals_section.code

Short description

Goals

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "61146-7"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:goals_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:goals_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:goals_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:goals_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:goals_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:goals_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

goals_entry

S C

0..*

Element id

Composition.section:goals_section.entry:goals_entry

Short description

A reference to data that supports this section

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:goals_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

0..*

see (section)

There are no (further) constraints on this element

Element id

Composition.section:goals_section.section

Short description

Nested Section

Definition

A nested sub-section within this section.

Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

health_concerns_section

S C

0..1

Element id

Composition.section:health_concerns_section

Short description

Health Concerns Section

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

1..1

Element id

Composition.section:health_concerns_section.title

Short description

title

Alternate names

header, label, caption

Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: ./title
cda: .title

code

1..1

CodeableConceptPattern

Element id

Composition.section:health_concerns_section.code

Short description

Health concerns section code

Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

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.

Data type

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "75310-3"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.author

Short description

Who and/or what authored the section

Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

1..1

Element id

Composition.section:health_concerns_section.text

Short description

text

Definition

Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.mode

Short description

working | snapshot | changes

Definition

Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.orderedBy

Short description

Order of section entries

Definition

Specifies the order applied to the items in the section entries.

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Comments

Data type

Binding

What order applies to the items in the entry.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

0..*

Element id

Composition.section:health_concerns_section.entry

Short description

entry

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Slicing

Unordered, Open, by resolve()(Profile)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

health_concerns_entry

S C

0..*

Element id

Composition.section:health_concerns_section.entry:health_concerns_entry

Short description

This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.

Definition

A reference to the actual resource from which the narrative in the section is derived.

Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1, cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

emptyReason

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Composition.section:health_concerns_section.emptyReason

Short description

Why the section is empty

Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

Data type

Binding

If a section is empty, why it is empty.