Profiles & Operations Index > Profile: Composition
Profile: Composition
Canonical URL:http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-composition
Simplifier project page: Composition (PS-ON)
Derived from: Composition (R4)
Formal Views of Profile Content
Description of Profiles, Differentials, Snapshots and how the different presentations work
Differential View
Composition | S I | Composition | Element IdComposition Ontario Patient Summary composition DefinitionOntario Patient Summary Composition. A Composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained. While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
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id | Σ | 0..1 | System.String | Element IdComposition.id Logical id of this artifact DefinitionLogical id of this artifact The only time that a resource does not have an id is when it is being submitted to the server using a create operation. System.String |
meta | S Σ | 1..1 | Meta | There are no (further) constraints on this element Element IdComposition.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
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versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element IdComposition.meta.versionId Version specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
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lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdComposition.meta.lastUpdated When the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed. This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
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source | Σ | 0..1 | uri | There are no (further) constraints on this element Element IdComposition.meta.source Identifies where the resource comes from DefinitionA uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
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profile | S Σ | 1..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element IdComposition.meta.profile Profiles this resource claims to conform to DefinitionA list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. canonical(StructureDefinition) Constraints
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security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element IdComposition.meta.security Security Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible)Constraints
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tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element IdComposition.meta.tag Tags applied to this resource DefinitionTags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource. The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". CommonTags (example)Constraints
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text | S | 0..1 | Narrative | There are no (further) constraints on this element Element IdComposition.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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identifier | S Σ | 1..1 | Identifier | There are no (further) constraints on this element Element IdComposition.identifier Version-independent identifier for the Composition DefinitionA version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time. Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.
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status | S Σ ?! | 1..1 | codeBinding | Element IdComposition.status preliminary | final | amended | entered-in-error DefinitionThe workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. Need to be able to mark interim, amended, or withdrawn compositions or documents. If a patient summary composition is marked as withdrawn, it should never be displayed to a user without a clear visual indicator to distinguish valid from invalid documents. The flag 'entered-in-error' is why this element is labeled as a modifier of other elements. The workflow/clinical status of the composition. CompositionStatus (required)Constraints
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type | S Σ | 1..1 | CodeableConceptBinding | Element IdComposition.type Kind of composition ("Patient Summary") DefinitionSpecifies that this composition refers to a Patient Summary (Loinc "60591-5") Key metadata element describing the composition, used in searching/filtering. For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. Type of a composition. FHIRDocumentTypeCodes (preferred)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "60591-5" } ] }
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category | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdComposition.category Categorization of Composition DefinitionA categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type. Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. This is a metadata field from XDS/MHD. High-level kind of a clinical document at a macro level. DocumentClassValueSet (example)Constraints
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subject | S Σ I | 0..1 | Reference(Patient (PS-ON)) | Element IdComposition.subject Who and/or what the composition is about DefinitionWho or what the composition is about. In general a composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). For the PS the subject is always the patient. Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. For clinical documents, this is usually the patient.
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reference | S Σ I | 1..1 | string | There are no (further) constraints on this element Element IdComposition.subject.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element IdComposition.subject.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). ResourceType (extensible)Constraints
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identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdComposition.subject.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdComposition.subject.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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encounter | Σ I | 0..1 | Reference(Encounter) | Element IdComposition.encounter Context of the Composition DefinitionDescribes the clinical encounter or type of care this documentation is associated with. Provides context for the composition and supports searching. While IPS-UV considers this a MS element, policy has not yet been developed in Canada confirming the expectations for when a patient summary is created (e.g., does it have to be created by a health professional or just validated, can it be automatically assembled, does it have to occur within an encounter, etc.) Further discussion is required to determine if systems will be expected to show they can construct an encounter resource in order to be conformant to the specification
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date | S Σ | 1..1 | dateTime | There are no (further) constraints on this element Element IdComposition.date Composition editing time DefinitionThe composition editing time, when the composition was last logically changed by the author. dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. The Last Modified Date on the composition may be after the date of the document was attested without being changed.
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author | S Σ I | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Element IdComposition.author Who and/or what authored the patient summary DefinitionThe Author is the Health Care Practitioner who reviews and signs off the Patient Summary composition before it is submitted to the repository. Where a HIC has opted into automated compilation and submission of a Patient Summary by the PoS System, the Author would instead be the PoS System. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Sliced:Unordered, Open, by resolve()(Profile) Constraints
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PractitionerRolePSON | S Σ I | 0..* | Reference(PractitionerRole (PS-ON)) | Element IdComposition.author:PractitionerRolePSON Who and/or what authored the patient summary DefinitionIdentifies who is responsible for the information in the patient summary, not necessarily who typed it in. The type of author(s) contribute to determine the "nature"of the Patient Summary: e.g. a "human-curated" PS Vs. an "automatically generated" PS. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(PractitionerRole (PS-ON)) Constraints
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DevicePSON | S Σ I | 0..* | Reference(Device (PS-ON)) | Element IdComposition.author:DevicePSON Who and/or what authored the patient summary DefinitionIdentifies who is responsible for the information in the patient summary, not necessarily who typed it in. The type of author(s) contribute to determine the "nature"of the Patient Summary: e.g. a "human-curated" PS Vs. an "automatically generated" PS. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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title | S Σ | 1..1 | string | Element IdComposition.title Ontario Patient Summary DefinitionOfficial human-readable label for the composition. For this document should be "Ontario Patient Summary" or any equivalent translation For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.
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confidentiality | S Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.confidentiality As defined by affinity domain DefinitionThe code specifying the level of confidentiality of the Composition. The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. Codes specifying the level of confidentiality of the composition. v3.ConfidentialityClassification (required)Constraints
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attester | S | 1..* | BackboneElement | There are no (further) constraints on this element Element IdComposition.attester Attests to accuracy of composition DefinitionA participant who has attested to the accuracy of the composition/document. Identifies responsibility for the accuracy of the composition content. Only list each attester once.
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mode | S | 1..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.attester.mode personal | professional | legal | official DefinitionThe type of attestation the authenticator offers. Indicates the level of authority of the attestation. Note that FHIR strings SHALL NOT exceed 1MB in size The way in which a person authenticated a composition. CompositionAttestationMode (required)Constraints
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time | S | 0..1 | dateTime | There are no (further) constraints on this element Element IdComposition.attester.time When the composition was attested DefinitionWhen the composition was attested by the party. Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).
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party | S I | 1..1 | Reference(PractitionerRole (PS-ON)) | Element IdComposition.attester.party Who attested the composition DefinitionWho attested the composition in the specified way. Identifies who has taken on the responsibility for accuracy of the composition content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(PractitionerRole (PS-ON)) Constraints
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custodian | S Σ I | 1..1 | Reference(Organization (PS-ON)) | Element IdComposition.custodian Organization which maintains the composition DefinitionIdentifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. Identifies where to go to find the current version, where to report issues, etc. This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged. Reference(Organization (PS-ON)) Constraints
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relatesTo | S | 0..* | BackboneElement | There are no (further) constraints on this element Element IdComposition.relatesTo Relationships to other compositions/documents DefinitionRelationships that this composition has with other compositions or documents that already exist. A document is a version specific composition.
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code | S | 1..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.relatesTo.code replaces | transforms | signs | appends DefinitionThe type of relationship that this composition has with anther composition or document. If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. The type of relationship between documents. DocumentRelationshipType (required)Constraints
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target[x] | S | 1..1 | There are no (further) constraints on this element Element IdComposition.relatesTo.target[x] Target of the relationship DefinitionThe target composition/document of this relationship.
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targetIdentifier | Identifier | There are no (further) constraints on this element Data Type | ||
targetReference | Reference(Composition) | There are no (further) constraints on this element Data Type | ||
event | S Σ | 0..* | BackboneElement | Element IdComposition.event The clinical service(s) being documented DefinitionThe main activity being described by a PS is the provision of healthcare over a period of time. In the CDA representation of the PS this is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. In the FHIR representation at lest one event should be used to record this information. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). For example if the PS is generated by a GP based on information recorded in his/her EHR-S, then the start value should represent the date when the treatment relationship between the patient and the GP started; and the end value the date of the latest care event. Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. The event needs to be consistent with the type element, though can provide further information if desired. Unordered, Open, by code(Pattern) Constraints
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code | Σ | 0..* | CodeableConceptBinding | Element IdComposition.event.code Code(s) that apply to the event being documented DefinitionThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries. This list of codes represents the main clinical acts being documented. v3.ActClass (preferred)Constraints
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element IdComposition.event.period The period covered by the documentation DefinitionThe period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.event.detail The event(s) being documented DefinitionThe description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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careProvisioningEvent | S Σ | 0..1 | BackboneElement | Element IdComposition.event:careProvisioningEvent The care provisioning being documented DefinitionThe provision of healthcare over a period of time this PS is documented. Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. The event needs to be consistent with the type element, though can provide further information if desired.
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code | S Σ | 1..* | CodeableConceptBinding | Element IdComposition.event:careProvisioningEvent.code Code(s) that apply to the event being documented DefinitionThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries. This list of codes represents the main clinical acts being documented. v3.ActClass (preferred)Constraints
{ "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ActClass", "code": "PCPR" } ] }
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coding | Σ | 1..* | Coding | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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system | Σ | 1..1 | uriFixed Value | Element IdComposition.event:careProvisioningEvent.code.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://terminology.hl7.org/CodeSystem/v3-ActClass
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | codeFixed Value | Element IdComposition.event:careProvisioningEvent.code.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
PCPR
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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period | S Σ I | 0..1 | Period | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.period The period covered by the documentation DefinitionThe period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.detail The event(s) being documented DefinitionThe description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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section | S I | 1..* | BackboneElement | Element IdComposition.section Sections composing the PS DefinitionThe root of the sections that make up the PS-ON composition. Unordered, Open, by code(Pattern) Constraints
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdComposition.section.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section.entry A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..* | see (section) | There are no (further) constraints on this element Element IdComposition.section.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionMedications | S I | 1..1 | BackboneElement | Element IdComposition.section:sectionMedications PS-ON Medication Summary Section DefinitionThe medication summary section contains a description of the patient's medications relevant for the scope of the patient summary. The actual content could depend on the jurisdiction, it could report:
This section requires either an entry indicating the subject is known not to be on any relevant medication; an entry indicating that no information is available about medications; or entries summarizing the subject's relevant medications.
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title | S | 1..1 | string | Element IdComposition.section:sectionMedications.title Medication Summary section Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Medication Summary Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionMedications.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "10160-0" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionMedications.entry Medications relevant for the scope of the patient summary DefinitionThis lists the medications relevant for the scope of the patient summary, or it is used to indicate either that the subject is known not to be on any relevant medication or that no information is available about medications. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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medicationInformation | S I | 1..* | Reference(Medication Statement (PS-ON) | Medication Request (PS-ON)) | Element IdComposition.section:sectionMedications.entry:medicationInformation A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Medication Statement (PS-ON) | Medication Request (PS-ON)) Constraints
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionAllergies | S I | 1..1 | BackboneElement | Element IdComposition.section:sectionAllergies PS-ON Allergies and Intolerances Section DefinitionThis section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..) and the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionAllergies.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "48765-2" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionAllergies.entry Relevant allergies or intolerances (conditions) for that patient. DefinitionIt lists the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..), the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. This entry shall be used to document that no information about allergies is available, or that no allergies are known. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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allergyOrIntolerance | S I | 1..* | Reference(Allergy Intolerance (PS-ON)) | Element IdComposition.section:sectionAllergies.entry:allergyOrIntolerance A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Allergy Intolerance (PS-ON)) Constraints
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionProblems | S I | 1..1 | BackboneElement | Element IdComposition.section:sectionProblems PS-ON Problems Section DefinitionThe PS problem section lists and describes clinical problems or conditions currently being monitored for the patient.
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionProblems.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "11450-4" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionProblems.entry Clinical problems or conditions currently being monitored for the patient. DefinitionIt lists and describes clinical problems or conditions currently being monitored for the patient. This entry shall be used to document that no information about problems is available, or that no relevant problems are known. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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problem | S I | 1..* | Reference(Condition (PS-ON)) | Element IdComposition.section:sectionProblems.entry:problem A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionProceduresHx | S I | 0..1 | BackboneElement | Element IdComposition.section:sectionProceduresHx PS-ON History of Procedures Section DefinitionThe History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to:
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionProceduresHx.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "47519-4" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionProceduresHx.entry Patient past procedures pertinent to the scope of this document. DefinitionIt lists the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to:
If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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procedure | S I | 1..* | Reference(Procedure (PS-ON)) | Element IdComposition.section:sectionProceduresHx.entry:procedure A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionImmunizations | S I | 0..1 | BackboneElement | Element IdComposition.section:sectionImmunizations PS-ON Immunizations Section DefinitionThe Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section includes the current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionImmunizations.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "11369-6" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionImmunizations.entry Patient's immunization status and pertinent history. DefinitionIt defines the patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. It may contain the entire immunization history that is relevant to the period of time being summarized. This entry shall be used to document that no information about immunizations is available, or that no immunizations are known. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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immunization | S I | 1..* | Reference(Immunization (PS-ON)) | Element IdComposition.section:sectionImmunizations.entry:immunization A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Immunization (PS-ON)) Constraints
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionPastIllnessHx | S I | 0..1 | BackboneElement | Element IdComposition.section:sectionPastIllnessHx PS-CA History of Past Illness Section DefinitionThe History of Past Illness section contains a description of the conditions the patient suffered in the past.
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionPastIllnessHx.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "11348-0" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionPastIllnessHx.entry Conditions the patient suffered in the past. DefinitionIt contains a description of the conditions the patient suffered in the past. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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pastProblem | S I | 1..* | Reference(Condition (PS-ON)) | Element IdComposition.section:sectionPastIllnessHx.entry:pastProblem A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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Hybrid View
Composition | S I | Composition | Element IdComposition Ontario Patient Summary composition DefinitionOntario Patient Summary Composition. A Composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained. While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
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id | Σ | 0..1 | System.String | Element IdComposition.id Logical id of this artifact DefinitionLogical id of this artifact The only time that a resource does not have an id is when it is being submitted to the server using a create operation. System.String |
meta | S Σ | 1..1 | Meta | There are no (further) constraints on this element Element IdComposition.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
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versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element IdComposition.meta.versionId Version specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
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lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdComposition.meta.lastUpdated When the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed. This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
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source | Σ | 0..1 | uri | There are no (further) constraints on this element Element IdComposition.meta.source Identifies where the resource comes from DefinitionA uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
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profile | S Σ | 1..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element IdComposition.meta.profile Profiles this resource claims to conform to DefinitionA list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. canonical(StructureDefinition) Constraints
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security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element IdComposition.meta.security Security Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible)Constraints
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tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element IdComposition.meta.tag Tags applied to this resource DefinitionTags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource. The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". CommonTags (example)Constraints
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text | S | 0..1 | Narrative | There are no (further) constraints on this element Element IdComposition.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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identifier | S Σ | 1..1 | Identifier | There are no (further) constraints on this element Element IdComposition.identifier Version-independent identifier for the Composition DefinitionA version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time. Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.
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status | S Σ ?! | 1..1 | codeBinding | Element IdComposition.status preliminary | final | amended | entered-in-error DefinitionThe workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. Need to be able to mark interim, amended, or withdrawn compositions or documents. If a patient summary composition is marked as withdrawn, it should never be displayed to a user without a clear visual indicator to distinguish valid from invalid documents. The flag 'entered-in-error' is why this element is labeled as a modifier of other elements. The workflow/clinical status of the composition. CompositionStatus (required)Constraints
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type | S Σ | 1..1 | CodeableConceptBinding | Element IdComposition.type Kind of composition ("Patient Summary") DefinitionSpecifies that this composition refers to a Patient Summary (Loinc "60591-5") Key metadata element describing the composition, used in searching/filtering. For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. Type of a composition. FHIRDocumentTypeCodes (preferred)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "60591-5" } ] }
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category | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdComposition.category Categorization of Composition DefinitionA categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type. Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. This is a metadata field from XDS/MHD. High-level kind of a clinical document at a macro level. DocumentClassValueSet (example)Constraints
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subject | S Σ I | 0..1 | Reference(Patient (PS-ON)) | Element IdComposition.subject Who and/or what the composition is about DefinitionWho or what the composition is about. In general a composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). For the PS the subject is always the patient. Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. For clinical documents, this is usually the patient.
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reference | S Σ I | 1..1 | string | There are no (further) constraints on this element Element IdComposition.subject.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element IdComposition.subject.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). ResourceType (extensible)Constraints
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identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdComposition.subject.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdComposition.subject.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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encounter | Σ I | 0..1 | Reference(Encounter) | Element IdComposition.encounter Context of the Composition DefinitionDescribes the clinical encounter or type of care this documentation is associated with. Provides context for the composition and supports searching. While IPS-UV considers this a MS element, policy has not yet been developed in Canada confirming the expectations for when a patient summary is created (e.g., does it have to be created by a health professional or just validated, can it be automatically assembled, does it have to occur within an encounter, etc.) Further discussion is required to determine if systems will be expected to show they can construct an encounter resource in order to be conformant to the specification
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date | S Σ | 1..1 | dateTime | There are no (further) constraints on this element Element IdComposition.date Composition editing time DefinitionThe composition editing time, when the composition was last logically changed by the author. dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. The Last Modified Date on the composition may be after the date of the document was attested without being changed.
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author | S Σ I | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Element IdComposition.author Who and/or what authored the patient summary DefinitionThe Author is the Health Care Practitioner who reviews and signs off the Patient Summary composition before it is submitted to the repository. Where a HIC has opted into automated compilation and submission of a Patient Summary by the PoS System, the Author would instead be the PoS System. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Sliced:Unordered, Open, by resolve()(Profile) Constraints
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PractitionerRolePSON | S Σ I | 0..* | Reference(PractitionerRole (PS-ON)) | Element IdComposition.author:PractitionerRolePSON Who and/or what authored the patient summary DefinitionIdentifies who is responsible for the information in the patient summary, not necessarily who typed it in. The type of author(s) contribute to determine the "nature"of the Patient Summary: e.g. a "human-curated" PS Vs. an "automatically generated" PS. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(PractitionerRole (PS-ON)) Constraints
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DevicePSON | S Σ I | 0..* | Reference(Device (PS-ON)) | Element IdComposition.author:DevicePSON Who and/or what authored the patient summary DefinitionIdentifies who is responsible for the information in the patient summary, not necessarily who typed it in. The type of author(s) contribute to determine the "nature"of the Patient Summary: e.g. a "human-curated" PS Vs. an "automatically generated" PS. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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title | S Σ | 1..1 | string | Element IdComposition.title Ontario Patient Summary DefinitionOfficial human-readable label for the composition. For this document should be "Ontario Patient Summary" or any equivalent translation For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.
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confidentiality | S Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.confidentiality As defined by affinity domain DefinitionThe code specifying the level of confidentiality of the Composition. The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. Codes specifying the level of confidentiality of the composition. v3.ConfidentialityClassification (required)Constraints
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attester | S | 1..* | BackboneElement | There are no (further) constraints on this element Element IdComposition.attester Attests to accuracy of composition DefinitionA participant who has attested to the accuracy of the composition/document. Identifies responsibility for the accuracy of the composition content. Only list each attester once.
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mode | S | 1..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.attester.mode personal | professional | legal | official DefinitionThe type of attestation the authenticator offers. Indicates the level of authority of the attestation. Note that FHIR strings SHALL NOT exceed 1MB in size The way in which a person authenticated a composition. CompositionAttestationMode (required)Constraints
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time | S | 0..1 | dateTime | There are no (further) constraints on this element Element IdComposition.attester.time When the composition was attested DefinitionWhen the composition was attested by the party. Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).
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party | S I | 1..1 | Reference(PractitionerRole (PS-ON)) | Element IdComposition.attester.party Who attested the composition DefinitionWho attested the composition in the specified way. Identifies who has taken on the responsibility for accuracy of the composition content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(PractitionerRole (PS-ON)) Constraints
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custodian | S Σ I | 1..1 | Reference(Organization (PS-ON)) | Element IdComposition.custodian Organization which maintains the composition DefinitionIdentifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. Identifies where to go to find the current version, where to report issues, etc. This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged. Reference(Organization (PS-ON)) Constraints
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relatesTo | S | 0..* | BackboneElement | There are no (further) constraints on this element Element IdComposition.relatesTo Relationships to other compositions/documents DefinitionRelationships that this composition has with other compositions or documents that already exist. A document is a version specific composition.
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code | S | 1..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.relatesTo.code replaces | transforms | signs | appends DefinitionThe type of relationship that this composition has with anther composition or document. If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. The type of relationship between documents. DocumentRelationshipType (required)Constraints
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target[x] | S | 1..1 | There are no (further) constraints on this element Element IdComposition.relatesTo.target[x] Target of the relationship DefinitionThe target composition/document of this relationship.
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targetIdentifier | Identifier | There are no (further) constraints on this element Data Type | ||
targetReference | Reference(Composition) | There are no (further) constraints on this element Data Type | ||
event | S Σ | 0..* | BackboneElement | Element IdComposition.event The clinical service(s) being documented DefinitionThe main activity being described by a PS is the provision of healthcare over a period of time. In the CDA representation of the PS this is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. In the FHIR representation at lest one event should be used to record this information. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). For example if the PS is generated by a GP based on information recorded in his/her EHR-S, then the start value should represent the date when the treatment relationship between the patient and the GP started; and the end value the date of the latest care event. Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. The event needs to be consistent with the type element, though can provide further information if desired. Unordered, Open, by code(Pattern) Constraints
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(All Slices) | There are no (further) constraints on this element | |||
code | Σ | 0..* | CodeableConceptBinding | Element IdComposition.event.code Code(s) that apply to the event being documented DefinitionThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries. This list of codes represents the main clinical acts being documented. v3.ActClass (preferred)Constraints
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element IdComposition.event.period The period covered by the documentation DefinitionThe period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.event.detail The event(s) being documented DefinitionThe description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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careProvisioningEvent | S Σ | 0..1 | BackboneElement | Element IdComposition.event:careProvisioningEvent The care provisioning being documented DefinitionThe provision of healthcare over a period of time this PS is documented. Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. The event needs to be consistent with the type element, though can provide further information if desired.
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code | S Σ | 1..* | CodeableConceptBinding | Element IdComposition.event:careProvisioningEvent.code Code(s) that apply to the event being documented DefinitionThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries. This list of codes represents the main clinical acts being documented. v3.ActClass (preferred)Constraints
{ "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ActClass", "code": "PCPR" } ] }
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coding | Σ | 1..* | Coding | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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system | Σ | 1..1 | uriFixed Value | Element IdComposition.event:careProvisioningEvent.code.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://terminology.hl7.org/CodeSystem/v3-ActClass
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | codeFixed Value | Element IdComposition.event:careProvisioningEvent.code.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
PCPR
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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period | S Σ I | 0..1 | Period | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.period The period covered by the documentation DefinitionThe period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.detail The event(s) being documented DefinitionThe description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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section | S I | 1..* | BackboneElement | Element IdComposition.section Sections composing the PS DefinitionThe root of the sections that make up the PS-ON composition. Unordered, Open, by code(Pattern) Constraints
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(All Slices) | There are no (further) constraints on this element | |||
title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdComposition.section.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section.entry A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..* | see (section) | There are no (further) constraints on this element Element IdComposition.section.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionMedications | S I | 1..1 | BackboneElement | Element IdComposition.section:sectionMedications PS-ON Medication Summary Section DefinitionThe medication summary section contains a description of the patient's medications relevant for the scope of the patient summary. The actual content could depend on the jurisdiction, it could report:
This section requires either an entry indicating the subject is known not to be on any relevant medication; an entry indicating that no information is available about medications; or entries summarizing the subject's relevant medications.
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title | S | 1..1 | string | Element IdComposition.section:sectionMedications.title Medication Summary section Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Medication Summary Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionMedications.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "10160-0" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionMedications.entry Medications relevant for the scope of the patient summary DefinitionThis lists the medications relevant for the scope of the patient summary, or it is used to indicate either that the subject is known not to be on any relevant medication or that no information is available about medications. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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medicationInformation | S I | 1..* | Reference(Medication Statement (PS-ON) | Medication Request (PS-ON)) | Element IdComposition.section:sectionMedications.entry:medicationInformation A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Medication Statement (PS-ON) | Medication Request (PS-ON)) Constraints
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionAllergies | S I | 1..1 | BackboneElement | Element IdComposition.section:sectionAllergies PS-ON Allergies and Intolerances Section DefinitionThis section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..) and the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionAllergies.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "48765-2" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionAllergies.entry Relevant allergies or intolerances (conditions) for that patient. DefinitionIt lists the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..), the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. This entry shall be used to document that no information about allergies is available, or that no allergies are known. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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allergyOrIntolerance | S I | 1..* | Reference(Allergy Intolerance (PS-ON)) | Element IdComposition.section:sectionAllergies.entry:allergyOrIntolerance A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Allergy Intolerance (PS-ON)) Constraints
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionProblems | S I | 1..1 | BackboneElement | Element IdComposition.section:sectionProblems PS-ON Problems Section DefinitionThe PS problem section lists and describes clinical problems or conditions currently being monitored for the patient.
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionProblems.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "11450-4" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionProblems.entry Clinical problems or conditions currently being monitored for the patient. DefinitionIt lists and describes clinical problems or conditions currently being monitored for the patient. This entry shall be used to document that no information about problems is available, or that no relevant problems are known. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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problem | S I | 1..* | Reference(Condition (PS-ON)) | Element IdComposition.section:sectionProblems.entry:problem A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionProceduresHx | S I | 0..1 | BackboneElement | Element IdComposition.section:sectionProceduresHx PS-ON History of Procedures Section DefinitionThe History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to:
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionProceduresHx.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "47519-4" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionProceduresHx.entry Patient past procedures pertinent to the scope of this document. DefinitionIt lists the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to:
If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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procedure | S I | 1..* | Reference(Procedure (PS-ON)) | Element IdComposition.section:sectionProceduresHx.entry:procedure A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionImmunizations | S I | 0..1 | BackboneElement | Element IdComposition.section:sectionImmunizations PS-ON Immunizations Section DefinitionThe Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section includes the current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionImmunizations.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "11369-6" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionImmunizations.entry Patient's immunization status and pertinent history. DefinitionIt defines the patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. It may contain the entire immunization history that is relevant to the period of time being summarized. This entry shall be used to document that no information about immunizations is available, or that no immunizations are known. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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immunization | S I | 1..* | Reference(Immunization (PS-ON)) | Element IdComposition.section:sectionImmunizations.entry:immunization A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Immunization (PS-ON)) Constraints
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionPastIllnessHx | S I | 0..1 | BackboneElement | Element IdComposition.section:sectionPastIllnessHx PS-CA History of Past Illness Section DefinitionThe History of Past Illness section contains a description of the conditions the patient suffered in the past.
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionPastIllnessHx.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "11348-0" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionPastIllnessHx.entry Conditions the patient suffered in the past. DefinitionIt contains a description of the conditions the patient suffered in the past. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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pastProblem | S I | 1..* | Reference(Condition (PS-ON)) | Element IdComposition.section:sectionPastIllnessHx.entry:pastProblem A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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Snapshot View
Composition | S I | Composition | Element IdComposition Ontario Patient Summary composition DefinitionOntario Patient Summary Composition. A Composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained. While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
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id | Σ | 0..1 | System.String | Element IdComposition.id Logical id of this artifact DefinitionLogical id of this artifact The only time that a resource does not have an id is when it is being submitted to the server using a create operation. System.String |
meta | S Σ | 1..1 | Meta | There are no (further) constraints on this element Element IdComposition.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
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versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element IdComposition.meta.versionId Version specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
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lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdComposition.meta.lastUpdated When the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed. This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
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source | Σ | 0..1 | uri | There are no (further) constraints on this element Element IdComposition.meta.source Identifies where the resource comes from DefinitionA uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
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profile | S Σ | 1..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element IdComposition.meta.profile Profiles this resource claims to conform to DefinitionA list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. canonical(StructureDefinition) Constraints
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security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element IdComposition.meta.security Security Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible)Constraints
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tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element IdComposition.meta.tag Tags applied to this resource DefinitionTags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource. The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". CommonTags (example)Constraints
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text | S | 0..1 | Narrative | There are no (further) constraints on this element Element IdComposition.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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identifier | S Σ | 1..1 | Identifier | There are no (further) constraints on this element Element IdComposition.identifier Version-independent identifier for the Composition DefinitionA version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time. Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.
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status | S Σ ?! | 1..1 | codeBinding | Element IdComposition.status preliminary | final | amended | entered-in-error DefinitionThe workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. Need to be able to mark interim, amended, or withdrawn compositions or documents. If a patient summary composition is marked as withdrawn, it should never be displayed to a user without a clear visual indicator to distinguish valid from invalid documents. The flag 'entered-in-error' is why this element is labeled as a modifier of other elements. The workflow/clinical status of the composition. CompositionStatus (required)Constraints
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type | S Σ | 1..1 | CodeableConceptBinding | Element IdComposition.type Kind of composition ("Patient Summary") DefinitionSpecifies that this composition refers to a Patient Summary (Loinc "60591-5") Key metadata element describing the composition, used in searching/filtering. For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. Type of a composition. FHIRDocumentTypeCodes (preferred)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "60591-5" } ] }
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category | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdComposition.category Categorization of Composition DefinitionA categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type. Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. This is a metadata field from XDS/MHD. High-level kind of a clinical document at a macro level. DocumentClassValueSet (example)Constraints
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subject | S Σ I | 0..1 | Reference(Patient (PS-ON)) | Element IdComposition.subject Who and/or what the composition is about DefinitionWho or what the composition is about. In general a composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). For the PS the subject is always the patient. Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. For clinical documents, this is usually the patient.
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reference | S Σ I | 1..1 | string | There are no (further) constraints on this element Element IdComposition.subject.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element IdComposition.subject.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). ResourceType (extensible)Constraints
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identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdComposition.subject.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdComposition.subject.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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encounter | Σ I | 0..1 | Reference(Encounter) | Element IdComposition.encounter Context of the Composition DefinitionDescribes the clinical encounter or type of care this documentation is associated with. Provides context for the composition and supports searching. While IPS-UV considers this a MS element, policy has not yet been developed in Canada confirming the expectations for when a patient summary is created (e.g., does it have to be created by a health professional or just validated, can it be automatically assembled, does it have to occur within an encounter, etc.) Further discussion is required to determine if systems will be expected to show they can construct an encounter resource in order to be conformant to the specification
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date | S Σ | 1..1 | dateTime | There are no (further) constraints on this element Element IdComposition.date Composition editing time DefinitionThe composition editing time, when the composition was last logically changed by the author. dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. The Last Modified Date on the composition may be after the date of the document was attested without being changed.
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author | S Σ I | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Element IdComposition.author Who and/or what authored the patient summary DefinitionThe Author is the Health Care Practitioner who reviews and signs off the Patient Summary composition before it is submitted to the repository. Where a HIC has opted into automated compilation and submission of a Patient Summary by the PoS System, the Author would instead be the PoS System. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Sliced:Unordered, Open, by resolve()(Profile) Constraints
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PractitionerRolePSON | S Σ I | 0..* | Reference(PractitionerRole (PS-ON)) | Element IdComposition.author:PractitionerRolePSON Who and/or what authored the patient summary DefinitionIdentifies who is responsible for the information in the patient summary, not necessarily who typed it in. The type of author(s) contribute to determine the "nature"of the Patient Summary: e.g. a "human-curated" PS Vs. an "automatically generated" PS. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(PractitionerRole (PS-ON)) Constraints
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DevicePSON | S Σ I | 0..* | Reference(Device (PS-ON)) | Element IdComposition.author:DevicePSON Who and/or what authored the patient summary DefinitionIdentifies who is responsible for the information in the patient summary, not necessarily who typed it in. The type of author(s) contribute to determine the "nature"of the Patient Summary: e.g. a "human-curated" PS Vs. an "automatically generated" PS. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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title | S Σ | 1..1 | string | Element IdComposition.title Ontario Patient Summary DefinitionOfficial human-readable label for the composition. For this document should be "Ontario Patient Summary" or any equivalent translation For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.
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confidentiality | S Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.confidentiality As defined by affinity domain DefinitionThe code specifying the level of confidentiality of the Composition. The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. Codes specifying the level of confidentiality of the composition. v3.ConfidentialityClassification (required)Constraints
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attester | S | 1..* | BackboneElement | There are no (further) constraints on this element Element IdComposition.attester Attests to accuracy of composition DefinitionA participant who has attested to the accuracy of the composition/document. Identifies responsibility for the accuracy of the composition content. Only list each attester once.
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mode | S | 1..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.attester.mode personal | professional | legal | official DefinitionThe type of attestation the authenticator offers. Indicates the level of authority of the attestation. Note that FHIR strings SHALL NOT exceed 1MB in size The way in which a person authenticated a composition. CompositionAttestationMode (required)Constraints
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time | S | 0..1 | dateTime | There are no (further) constraints on this element Element IdComposition.attester.time When the composition was attested DefinitionWhen the composition was attested by the party. Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).
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party | S I | 1..1 | Reference(PractitionerRole (PS-ON)) | Element IdComposition.attester.party Who attested the composition DefinitionWho attested the composition in the specified way. Identifies who has taken on the responsibility for accuracy of the composition content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(PractitionerRole (PS-ON)) Constraints
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custodian | S Σ I | 1..1 | Reference(Organization (PS-ON)) | Element IdComposition.custodian Organization which maintains the composition DefinitionIdentifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. Identifies where to go to find the current version, where to report issues, etc. This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged. Reference(Organization (PS-ON)) Constraints
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relatesTo | S | 0..* | BackboneElement | There are no (further) constraints on this element Element IdComposition.relatesTo Relationships to other compositions/documents DefinitionRelationships that this composition has with other compositions or documents that already exist. A document is a version specific composition.
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code | S | 1..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.relatesTo.code replaces | transforms | signs | appends DefinitionThe type of relationship that this composition has with anther composition or document. If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. The type of relationship between documents. DocumentRelationshipType (required)Constraints
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target[x] | S | 1..1 | There are no (further) constraints on this element Element IdComposition.relatesTo.target[x] Target of the relationship DefinitionThe target composition/document of this relationship.
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targetIdentifier | Identifier | There are no (further) constraints on this element Data Type | ||
targetReference | Reference(Composition) | There are no (further) constraints on this element Data Type | ||
event | S Σ | 0..* | BackboneElement | Element IdComposition.event The clinical service(s) being documented DefinitionThe main activity being described by a PS is the provision of healthcare over a period of time. In the CDA representation of the PS this is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. In the FHIR representation at lest one event should be used to record this information. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). For example if the PS is generated by a GP based on information recorded in his/her EHR-S, then the start value should represent the date when the treatment relationship between the patient and the GP started; and the end value the date of the latest care event. Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. The event needs to be consistent with the type element, though can provide further information if desired. Unordered, Open, by code(Pattern) Constraints
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(All Slices) | There are no (further) constraints on this element | |||
code | Σ | 0..* | CodeableConceptBinding | Element IdComposition.event.code Code(s) that apply to the event being documented DefinitionThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries. This list of codes represents the main clinical acts being documented. v3.ActClass (preferred)Constraints
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element IdComposition.event.period The period covered by the documentation DefinitionThe period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.event.detail The event(s) being documented DefinitionThe description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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careProvisioningEvent | S Σ | 0..1 | BackboneElement | Element IdComposition.event:careProvisioningEvent The care provisioning being documented DefinitionThe provision of healthcare over a period of time this PS is documented. Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. The event needs to be consistent with the type element, though can provide further information if desired.
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code | S Σ | 1..* | CodeableConceptBinding | Element IdComposition.event:careProvisioningEvent.code Code(s) that apply to the event being documented DefinitionThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries. This list of codes represents the main clinical acts being documented. v3.ActClass (preferred)Constraints
{ "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ActClass", "code": "PCPR" } ] }
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coding | Σ | 1..* | Coding | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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system | Σ | 1..1 | uriFixed Value | Element IdComposition.event:careProvisioningEvent.code.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://terminology.hl7.org/CodeSystem/v3-ActClass
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | codeFixed Value | Element IdComposition.event:careProvisioningEvent.code.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
PCPR
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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period | S Σ I | 0..1 | Period | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.period The period covered by the documentation DefinitionThe period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.event:careProvisioningEvent.detail The event(s) being documented DefinitionThe description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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section | S I | 1..* | BackboneElement | Element IdComposition.section Sections composing the PS DefinitionThe root of the sections that make up the PS-ON composition. Unordered, Open, by code(Pattern) Constraints
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(All Slices) | There are no (further) constraints on this element | |||
title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdComposition.section.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section.entry A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..* | see (section) | There are no (further) constraints on this element Element IdComposition.section.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionMedications | S I | 1..1 | BackboneElement | Element IdComposition.section:sectionMedications PS-ON Medication Summary Section DefinitionThe medication summary section contains a description of the patient's medications relevant for the scope of the patient summary. The actual content could depend on the jurisdiction, it could report:
This section requires either an entry indicating the subject is known not to be on any relevant medication; an entry indicating that no information is available about medications; or entries summarizing the subject's relevant medications.
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title | S | 1..1 | string | Element IdComposition.section:sectionMedications.title Medication Summary section Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Medication Summary Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionMedications.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "10160-0" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionMedications.entry Medications relevant for the scope of the patient summary DefinitionThis lists the medications relevant for the scope of the patient summary, or it is used to indicate either that the subject is known not to be on any relevant medication or that no information is available about medications. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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medicationInformation | S I | 1..* | Reference(Medication Statement (PS-ON) | Medication Request (PS-ON)) | Element IdComposition.section:sectionMedications.entry:medicationInformation A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Medication Statement (PS-ON) | Medication Request (PS-ON)) Constraints
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionMedications.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionAllergies | S I | 1..1 | BackboneElement | Element IdComposition.section:sectionAllergies PS-ON Allergies and Intolerances Section DefinitionThis section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..) and the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionAllergies.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "48765-2" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionAllergies.entry Relevant allergies or intolerances (conditions) for that patient. DefinitionIt lists the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..), the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. This entry shall be used to document that no information about allergies is available, or that no allergies are known. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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allergyOrIntolerance | S I | 1..* | Reference(Allergy Intolerance (PS-ON)) | Element IdComposition.section:sectionAllergies.entry:allergyOrIntolerance A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Allergy Intolerance (PS-ON)) Constraints
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionAllergies.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionProblems | S I | 1..1 | BackboneElement | Element IdComposition.section:sectionProblems PS-ON Problems Section DefinitionThe PS problem section lists and describes clinical problems or conditions currently being monitored for the patient.
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionProblems.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "11450-4" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionProblems.entry Clinical problems or conditions currently being monitored for the patient. DefinitionIt lists and describes clinical problems or conditions currently being monitored for the patient. This entry shall be used to document that no information about problems is available, or that no relevant problems are known. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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problem | S I | 1..* | Reference(Condition (PS-ON)) | Element IdComposition.section:sectionProblems.entry:problem A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionProblems.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionProceduresHx | S I | 0..1 | BackboneElement | Element IdComposition.section:sectionProceduresHx PS-ON History of Procedures Section DefinitionThe History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to:
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionProceduresHx.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "47519-4" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionProceduresHx.entry Patient past procedures pertinent to the scope of this document. DefinitionIt lists the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to:
If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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procedure | S I | 1..* | Reference(Procedure (PS-ON)) | Element IdComposition.section:sectionProceduresHx.entry:procedure A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionProceduresHx.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionImmunizations | S I | 0..1 | BackboneElement | Element IdComposition.section:sectionImmunizations PS-ON Immunizations Section DefinitionThe Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section includes the current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionImmunizations.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "11369-6" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionImmunizations.entry Patient's immunization status and pertinent history. DefinitionIt defines the patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. It may contain the entire immunization history that is relevant to the period of time being summarized. This entry shall be used to document that no information about immunizations is available, or that no immunizations are known. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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immunization | S I | 1..* | Reference(Immunization (PS-ON)) | Element IdComposition.section:sectionImmunizations.entry:immunization A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Immunization (PS-ON)) Constraints
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionImmunizations.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionPastIllnessHx | S I | 0..1 | BackboneElement | Element IdComposition.section:sectionPastIllnessHx PS-CA History of Past Illness Section DefinitionThe History of Past Illness section contains a description of the conditions the patient suffered in the past.
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title | S | 1..1 | string | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConcept | Element IdComposition.section:sectionPastIllnessHx.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document. DocumentSectionCodes (example)Constraints
{ "coding": [ { "system": "http://loinc.org", "code": "11348-0" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section. ListMode (required)Constraints
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry. ListOrderCodes (preferred)Constraints
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entry | S I | 1..* | Reference(Resource) | Element IdComposition.section:sectionPastIllnessHx.entry Conditions the patient suffered in the past. DefinitionIt contains a description of the conditions the patient suffered in the past. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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pastProblem | S I | 1..* | Reference(Condition (PS-ON)) | Element IdComposition.section:sectionPastIllnessHx.entry:pastProblem A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty. ListEmptyReasons (preferred)Constraints
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element IdComposition.section:sectionPastIllnessHx.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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Table View
Composition | .. | |
Composition.id | .. | |
Composition.meta | 1.. | |
Composition.meta.profile | 1.. | |
Composition.text | .. | |
Composition.identifier | 1.. | |
Composition.status | .. | |
Composition.type | 1.. | |
Composition.subject | Reference(Patient (PS-ON)) | .. |
Composition.subject.reference | 1.. | |
Composition.encounter | .. | |
Composition.date | .. | |
Composition.author | .. | |
Composition.author | Reference(PractitionerRole (PS-ON)) | 0.. |
Composition.author | Reference(Device (PS-ON)) | 0.. |
Composition.title | .. | |
Composition.confidentiality | .. | |
Composition.attester | 1.. | |
Composition.attester.mode | .. | |
Composition.attester.time | .. | |
Composition.attester.party | Reference(PractitionerRole (PS-ON)) | 1.. |
Composition.custodian | Reference(Organization (PS-ON)) | 1.. |
Composition.relatesTo | .. | |
Composition.relatesTo.code | .. | |
Composition.relatesTo.target[x] | .. | |
Composition.event | .. | |
Composition.event.code | .. | |
Composition.event | ..1 | |
Composition.event.code | 1.. | |
Composition.event.code.coding | 1.. | |
Composition.event.code.coding.system | 1.. | |
Composition.event.code.coding.code | 1.. | |
Composition.event.period | .. | |
Composition.section | 1.. | |
Composition.section | 1..1 | |
Composition.section.title | 1.. | |
Composition.section.code | 1.. | |
Composition.section.text | Narrative | 1.. |
Composition.section.entry | 1.. | |
Composition.section.entry | Reference(Medication Statement (PS-ON) | Medication Request (PS-ON)) | 1.. |
Composition.section.emptyReason | ..0 | |
Composition.section.section | ..0 | |
Composition.section | 1..1 | |
Composition.section.title | 1.. | |
Composition.section.code | 1.. | |
Composition.section.text | Narrative | 1.. |
Composition.section.entry | 1.. | |
Composition.section.entry | Reference(Allergy Intolerance (PS-ON)) | 1.. |
Composition.section.emptyReason | ..0 | |
Composition.section.section | ..0 | |
Composition.section | 1..1 | |
Composition.section.title | 1.. | |
Composition.section.code | 1.. | |
Composition.section.text | Narrative | 1.. |
Composition.section.entry | 1.. | |
Composition.section.entry | Reference(Condition (PS-ON)) | 1.. |
Composition.section.emptyReason | ..0 | |
Composition.section.section | ..0 | |
Composition.section | ..1 | |
Composition.section.title | 1.. | |
Composition.section.code | 1.. | |
Composition.section.text | Narrative | 1.. |
Composition.section.entry | 1.. | |
Composition.section.entry | Reference(Procedure (PS-ON)) | 1.. |
Composition.section.emptyReason | ..0 | |
Composition.section.section | ..0 | |
Composition.section | ..1 | |
Composition.section.title | 1.. | |
Composition.section.code | 1.. | |
Composition.section.text | Narrative | 1.. |
Composition.section.entry | 1.. | |
Composition.section.entry | Reference(Immunization (PS-ON)) | 1.. |
Composition.section.emptyReason | ..0 | |
Composition.section.section | ..0 | |
Composition.section | ..1 | |
Composition.section.title | 1.. | |
Composition.section.code | 1.. | |
Composition.section.text | 1.. | |
Composition.section.entry | 1.. | |
Composition.section.entry | Reference(Condition (PS-ON)) | 1.. |
Composition.section.emptyReason | ..0 | |
Composition.section.section | ..0 |
JSON View
{ "resourceType": "StructureDefinition", "id": "ca-on-ps-profile-composition", "url": "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-composition", "version": "0.9.1", "name": "CompositionPSON", "title": "Composition (PS-ON)", "status": "draft", "date": "2021-10-04T11:30:20+00:00", "publisher": "Ontario Health", "description": "This profile defines a set of constraints to the FHIR Composition resource for use in Ontario Patient Summaries (PS-ON). It refines constraints applied to the Composition resource by the PS-CA project.\nA Canadian Patient Summary (PS-CA) document is an electronic health record extract containing essential healthcare information about a subject of care. It is informed by the IPS-UV Composition profile, but differs in its application of MS flags on some of the sections to allow for jurisdictional implementors flexibility in what sections systems must support in order to show conformance to their respective patient summaries.\nThe PS-CA dataset is minimal and non-exhaustive; specialty-agnostic and condition-independent; but still clinically relevant. Its informed by the requirements specified in EN 17269 and ISO/DIS 27269, it is designed for supporting the international use case scenario for ‘unplanned, cross border care’, but is also designed to support a variety of use cases for cross-jurisdiction exchange. It is intended to guide implementation nationally while ensuring international exchange of patient summaries is not impeded.\n\nThis profile is based on the ClinicalDocument profile from the base R4 FHIR standard.", "kind": "resource", "abstract": false, "type": "Composition", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Composition", "derivation": "constraint", "differential": { "element": [ { "id": "Composition", "path": "Composition", "short": "Ontario Patient Summary composition", "definition": "Ontario Patient Summary Composition. \nA Composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. \nWhile a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.", "mustSupport": true }, { "id": "Composition.id", "path": "Composition.id", "definition": "Logical id of this artifact" }, { "id": "Composition.meta", "path": "Composition.meta", "min": 1, "mustSupport": true }, { "id": "Composition.meta.profile", "path": "Composition.meta.profile", "min": 1, "mustSupport": true }, { "id": "Composition.text", "path": "Composition.text", "mustSupport": true }, { "id": "Composition.identifier", "path": "Composition.identifier", "mustSupport": true, "min": 1 }, { "id": "Composition.status", "path": "Composition.status", "comment": "If a patient summary composition is marked as withdrawn, it should never be displayed to a user without a clear visual indicator to distinguish valid from invalid documents. The flag 'entered-in-error' is why this element is labeled as a modifier of other elements.", "mustSupport": true }, { "id": "Composition.type", "path": "Composition.type", "short": "Kind of composition (\"Patient Summary\")", "definition": "Specifies that this composition refers to a Patient Summary (Loinc \"60591-5\")", "min": 1, "patternCodeableConcept": { "coding": [ { "system": "http://loinc.org", "code": "60591-5" } ] }, "mustSupport": true }, { "id": "Composition.subject", "path": "Composition.subject", "definition": "Who or what the composition is about. \nIn general a composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).\nFor the PS the subject is always the patient.", "type": [ { "code": "Reference", "targetProfile": [ "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-patient" ] } ], "mustSupport": true }, { "id": "Composition.subject.reference", "path": "Composition.subject.reference", "min": 1, "mustSupport": true }, { "id": "Composition.encounter", "path": "Composition.encounter", "comment": "While IPS-UV considers this a MS element, policy has not yet been developed in Canada confirming the expectations for when a patient summary is created (e.g., does it have to be created by a health professional or just validated, can it be automatically assembled, does it have to occur within an encounter, etc.) Further discussion is required to determine if systems will be expected to show they can construct an encounter resource in order to be conformant to the specification" }, { "id": "Composition.date", "path": "Composition.date", "mustSupport": true }, { "id": "Composition.author", "path": "Composition.author", "short": "Who and/or what authored the patient summary", "definition": "The Author is the Health Care Practitioner who reviews and signs off the Patient Summary composition before it is submitted to the repository. Where a HIC has opted into automated compilation and submission of a Patient Summary by the PoS System, the Author would instead be the PoS System.", "slicing": { "discriminator": [ { "type": "profile", "path": "resolve()" } ], "rules": "open" }, "mustSupport": true }, { "id": "Composition.author:PractitionerRolePSON", "path": "Composition.author", "sliceName": "PractitionerRolePSON", "short": "Who and/or what authored the patient summary", "definition": "Identifies who is responsible for the information in the patient summary, not necessarily who typed it in.\n\nThe type of author(s) contribute to determine the \"nature\"of the Patient Summary: e.g. a \"human-curated\" PS Vs. an \"automatically generated\" PS.", "type": [ { "code": "Reference", "targetProfile": [ "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-practitionerrole" ] } ], "min": 0, "mustSupport": true }, { "id": "Composition.author:DevicePSON", "path": "Composition.author", "sliceName": "DevicePSON", "short": "Who and/or what authored the patient summary", "definition": "Identifies who is responsible for the information in the patient summary, not necessarily who typed it in.\n\nThe type of author(s) contribute to determine the \"nature\"of the Patient Summary: e.g. a \"human-curated\" PS Vs. an \"automatically generated\" PS.", "type": [ { "code": "Reference", "targetProfile": [ "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-device" ] } ], "min": 0, "mustSupport": true }, { "id": "Composition.title", "path": "Composition.title", "short": "Ontario Patient Summary", "definition": "Official human-readable label for the composition.\n\nFor this document should be \"Ontario Patient Summary\" or any equivalent translation", "mustSupport": true }, { "id": "Composition.confidentiality", "path": "Composition.confidentiality", "mustSupport": true }, { "id": "Composition.attester", "path": "Composition.attester", "min": 1, "mustSupport": true }, { "id": "Composition.attester.mode", "path": "Composition.attester.mode", "mustSupport": true }, { "id": "Composition.attester.time", "path": "Composition.attester.time", "mustSupport": true }, { "id": "Composition.attester.party", "path": "Composition.attester.party", "mustSupport": true, "min": 1, "type": [ { "code": "Reference", "targetProfile": [ "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-practitionerrole" ] } ] }, { "id": "Composition.custodian", "path": "Composition.custodian", "type": [ { "code": "Reference", "targetProfile": [ "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-organization" ] } ], "min": 1, "mustSupport": true }, { "id": "Composition.relatesTo", "path": "Composition.relatesTo", "mustSupport": true }, { "id": "Composition.relatesTo.code", "path": "Composition.relatesTo.code", "mustSupport": true }, { "id": "Composition.relatesTo.target[x]", "path": "Composition.relatesTo.target[x]", "mustSupport": true }, { "id": "Composition.event", "path": "Composition.event", "slicing": { "discriminator": [ { "type": "pattern", "path": "code" } ], "rules": "open" }, "definition": "The main activity being described by a PS is the provision of healthcare over a period of time. \nIn the CDA representation of the PS this is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. \nIn the FHIR representation at lest one event should be used to record this information.\nAdditional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). For example if the PS is generated by a GP based on information recorded in his/her EHR-S, then the start value should represent the date when the treatment relationship between the patient and the GP started; and the end value the date of the latest care event.", "mustSupport": true }, { "id": "Composition.event.code", "path": "Composition.event.code", "binding": { "strength": "preferred", "valueSet": "http://terminology.hl7.org/CodeSystem/v3-ActClass" } }, { "id": "Composition.event:careProvisioningEvent", "path": "Composition.event", "sliceName": "careProvisioningEvent", "short": "The care provisioning being documented", "definition": "The provision of healthcare over a period of time this PS is documented.", "max": "1", "mustSupport": true }, { "id": "Composition.event:careProvisioningEvent.code", "path": "Composition.event.code", "min": 1, "patternCodeableConcept": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ActClass", "code": "PCPR" } ] }, "binding": { "strength": "preferred", "valueSet": "http://terminology.hl7.org/CodeSystem/v3-ActClass" }, "mustSupport": true }, { "id": "Composition.event:careProvisioningEvent.code.coding", "path": "Composition.event.code.coding", "min": 1 }, { "id": "Composition.event:careProvisioningEvent.code.coding.system", "path": "Composition.event.code.coding.system", "min": 1, "fixedCode": "http://terminology.hl7.org/CodeSystem/v3-ActClass" }, { "id": "Composition.event:careProvisioningEvent.code.coding.code", "path": "Composition.event.code.coding.code", "min": 1, "fixedCode": "PCPR" }, { "id": "Composition.event:careProvisioningEvent.period", "path": "Composition.event.period", "mustSupport": true }, { "id": "Composition.section", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "slicing": { "discriminator": [ { "type": "pattern", "path": "code" } ], "ordered": false, "rules": "open" }, "short": "Sections composing the PS", "definition": "The root of the sections that make up the PS-ON composition.", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionMedications", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "sectionMedications", "short": "PS-ON Medication Summary Section", "definition": "The medication summary section contains a description of the patient's medications relevant for the scope of the patient summary.\nThe actual content could depend on the jurisdiction, it could report:\n- the currently active medications; \n- the current and past medications considered relevant by the authoring GP; \n- the patient prescriptions or dispensations automatically extracted by a regional or a national EHR.\n\n This section requires either an entry indicating the subject is known not to be on any relevant medication; an entry indicating that no information is available about medications; or entries summarizing the subject's relevant medications.", "min": 1, "max": "1", "mustSupport": true }, { "id": "Composition.section:sectionMedications.title", "path": "Composition.section.title", "short": "Medication Summary section", "definition": "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.\n\nMedication Summary", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionMedications.code", "path": "Composition.section.code", "min": 1, "patternCodeableConcept": { "coding": [ { "system": "http://loinc.org", "code": "10160-0" } ] }, "mustSupport": true }, { "id": "Composition.section:sectionMedications.text", "path": "Composition.section.text", "min": 1, "type": [ { "code": "Narrative" } ], "mustSupport": true }, { "id": "Composition.section:sectionMedications.entry", "path": "Composition.section.entry", "slicing": { "discriminator": [ { "type": "profile", "path": "resolve()" } ], "rules": "open" }, "short": "Medications relevant for the scope of the patient summary", "definition": "This lists the medications relevant for the scope of the patient summary, or it is used to indicate either that the subject is known not to be on any relevant medication or that no information is available about medications.", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionMedications.entry:medicationInformation", "path": "Composition.section.entry", "sliceName": "medicationInformation", "min": 1, "type": [ { "code": "Reference", "targetProfile": [ "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-medicationstatement", "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-medicationrequest" ] } ], "mustSupport": true }, { "id": "Composition.section:sectionMedications.emptyReason", "path": "Composition.section.emptyReason", "max": "0", "mustSupport": false }, { "id": "Composition.section:sectionMedications.section", "path": "Composition.section.section", "max": "0", "mustSupport": false }, { "id": "Composition.section:sectionAllergies", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "sectionAllergies", "short": "PS-ON Allergies and Intolerances Section", "definition": "This section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..) and the agents that cause it; and optionally the criticality and the certainty of the allergy.\nAt a minimum, it should list currently active and any relevant historical allergies and adverse reactions.\nIf no information about allergies is available, or if no allergies are known this should be clearly documented in the section.", "min": 1, "max": "1", "mustSupport": true }, { "id": "Composition.section:sectionAllergies.title", "path": "Composition.section.title", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionAllergies.code", "path": "Composition.section.code", "min": 1, "patternCodeableConcept": { "coding": [ { "system": "http://loinc.org", "code": "48765-2" } ] }, "mustSupport": true }, { "id": "Composition.section:sectionAllergies.text", "path": "Composition.section.text", "min": 1, "type": [ { "code": "Narrative" } ], "mustSupport": true }, { "id": "Composition.section:sectionAllergies.entry", "path": "Composition.section.entry", "slicing": { "discriminator": [ { "type": "profile", "path": "resolve()" } ], "rules": "open" }, "short": "Relevant allergies or intolerances (conditions) for that patient.", "definition": "It lists the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis,..), the agents that cause it; and optionally the criticality and the certainty of the allergy.\nAt a minimum, it should list currently active and any relevant historical allergies and adverse reactions.\n This entry shall be used to document that no information about allergies is available, or that no allergies are known.", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionAllergies.entry:allergyOrIntolerance", "path": "Composition.section.entry", "sliceName": "allergyOrIntolerance", "min": 1, "type": [ { "code": "Reference", "targetProfile": [ "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-allergyintolerance" ] } ], "mustSupport": true }, { "id": "Composition.section:sectionAllergies.emptyReason", "path": "Composition.section.emptyReason", "max": "0", "mustSupport": false }, { "id": "Composition.section:sectionAllergies.section", "path": "Composition.section.section", "max": "0", "mustSupport": false }, { "id": "Composition.section:sectionProblems", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "sectionProblems", "short": "PS-ON Problems Section", "definition": "The PS problem section lists and describes clinical problems or conditions currently being monitored for the patient.", "min": 1, "max": "1", "mustSupport": true }, { "id": "Composition.section:sectionProblems.title", "path": "Composition.section.title", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionProblems.code", "path": "Composition.section.code", "min": 1, "patternCodeableConcept": { "coding": [ { "system": "http://loinc.org", "code": "11450-4" } ] }, "mustSupport": true }, { "id": "Composition.section:sectionProblems.text", "path": "Composition.section.text", "min": 1, "type": [ { "code": "Narrative" } ], "mustSupport": true }, { "id": "Composition.section:sectionProblems.entry", "path": "Composition.section.entry", "slicing": { "discriminator": [ { "type": "profile", "path": "resolve()" } ], "rules": "open" }, "short": "Clinical problems or conditions currently being monitored for the patient.", "definition": "It lists and describes clinical problems or conditions currently being monitored for the patient. This entry shall be used to document that no information about problems is available, or that no relevant problems are known.", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionProblems.entry:problem", "path": "Composition.section.entry", "sliceName": "problem", "min": 1, "type": [ { "code": "Reference", "targetProfile": [ "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-condition" ] } ], "mustSupport": true }, { "id": "Composition.section:sectionProblems.emptyReason", "path": "Composition.section.emptyReason", "max": "0", "mustSupport": false }, { "id": "Composition.section:sectionProblems.section", "path": "Composition.section.section", "max": "0", "mustSupport": false }, { "id": "Composition.section:sectionProceduresHx", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "sectionProceduresHx", "short": "PS-ON History of Procedures Section", "definition": "The History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document.\nProcedures may refer for example to:\n1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)\n2. Therapeutic procedure: e.g. dialysis;\n3. Surgical procedure: e.g. appendectomy", "max": "1", "mustSupport": true }, { "id": "Composition.section:sectionProceduresHx.title", "path": "Composition.section.title", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionProceduresHx.code", "path": "Composition.section.code", "min": 1, "patternCodeableConcept": { "coding": [ { "system": "http://loinc.org", "code": "47519-4" } ] }, "mustSupport": true }, { "id": "Composition.section:sectionProceduresHx.text", "path": "Composition.section.text", "min": 1, "type": [ { "code": "Narrative" } ], "mustSupport": true }, { "id": "Composition.section:sectionProceduresHx.entry", "path": "Composition.section.entry", "slicing": { "discriminator": [ { "type": "profile", "path": "resolve()" } ], "rules": "open" }, "short": "Patient past procedures pertinent to the scope of this document.", "definition": "It lists the patient past procedures that are pertinent to the scope of this document.\nProcedures may refer for example to:\n1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)\n2. Therapeutic procedure: e.g. dialysis;\n3. Surgical procedure: e.g. appendectomy. This entry shall be used to document that no information about past procedures is available, or that no relevant past procedures are known.", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionProceduresHx.entry:procedure", "path": "Composition.section.entry", "sliceName": "procedure", "min": 1, "type": [ { "code": "Reference", "targetProfile": [ "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-procedure" ] } ], "mustSupport": true }, { "id": "Composition.section:sectionProceduresHx.emptyReason", "path": "Composition.section.emptyReason", "max": "0", "mustSupport": false }, { "id": "Composition.section:sectionProceduresHx.section", "path": "Composition.section.section", "max": "0", "mustSupport": false }, { "id": "Composition.section:sectionImmunizations", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "sectionImmunizations", "short": "PS-ON Immunizations Section", "definition": "The Immunizations Section defines a patient's current immunization status and pertinent immunization history.\nThe primary use case for the Immunization Section is to enable communication of a patient's immunization status.\nThe section includes the current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.", "max": "1", "mustSupport": true }, { "id": "Composition.section:sectionImmunizations.title", "path": "Composition.section.title", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionImmunizations.code", "path": "Composition.section.code", "min": 1, "patternCodeableConcept": { "coding": [ { "system": "http://loinc.org", "code": "11369-6" } ] }, "mustSupport": true }, { "id": "Composition.section:sectionImmunizations.text", "path": "Composition.section.text", "min": 1, "type": [ { "code": "Narrative" } ], "mustSupport": true }, { "id": "Composition.section:sectionImmunizations.entry", "path": "Composition.section.entry", "slicing": { "discriminator": [ { "type": "profile", "path": "resolve()" } ], "rules": "open" }, "short": "Patient's immunization status and pertinent history.", "definition": "It defines the patient's current immunization status and pertinent immunization history.\nThe primary use case for the Immunization Section is to enable communication of a patient's immunization status.\nIt may contain the entire immunization history that is relevant to the period of time being summarized. This entry shall be used to document that no information about immunizations is available, or that no immunizations are known.", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionImmunizations.entry:immunization", "path": "Composition.section.entry", "sliceName": "immunization", "min": 1, "type": [ { "code": "Reference", "targetProfile": [ "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-immunization" ] } ], "mustSupport": true }, { "id": "Composition.section:sectionImmunizations.emptyReason", "path": "Composition.section.emptyReason", "max": "0", "mustSupport": false }, { "id": "Composition.section:sectionImmunizations.section", "path": "Composition.section.section", "max": "0", "mustSupport": false }, { "id": "Composition.section:sectionPastIllnessHx", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "sectionPastIllnessHx", "short": "PS-CA History of Past Illness Section", "definition": "The History of Past Illness section contains a description of the conditions the patient suffered in the past.", "max": "1", "mustSupport": true }, { "id": "Composition.section:sectionPastIllnessHx.title", "path": "Composition.section.title", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionPastIllnessHx.code", "path": "Composition.section.code", "min": 1, "patternCodeableConcept": { "coding": [ { "system": "http://loinc.org", "code": "11348-0" } ] }, "mustSupport": true }, { "id": "Composition.section:sectionPastIllnessHx.text", "path": "Composition.section.text", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionPastIllnessHx.entry", "path": "Composition.section.entry", "slicing": { "discriminator": [ { "type": "profile", "path": "resolve()" } ], "rules": "open" }, "short": "Conditions the patient suffered in the past.", "definition": "It contains a description of the conditions the patient suffered in the past.", "min": 1, "mustSupport": true }, { "id": "Composition.section:sectionPastIllnessHx.entry:pastProblem", "path": "Composition.section.entry", "sliceName": "pastProblem", "min": 1, "type": [ { "code": "Reference", "targetProfile": [ "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-condition" ] } ], "mustSupport": true }, { "id": "Composition.section:sectionPastIllnessHx.emptyReason", "path": "Composition.section.emptyReason", "max": "0", "mustSupport": false }, { "id": "Composition.section:sectionPastIllnessHx.section", "path": "Composition.section.section", "max": "0", "mustSupport": false } ] } }
Usage
The Composition Resource is used to represent the Patient Summary data set as a document.
Notes
.id
- used to uniquely identify the resource
- if a persistent identity for the resource is not available to use when constructing the composition Bundle, a UUID SHOULD be used in this element (with a corresponding value in
Bundle.entry.fullUrl
) - Where
.id
is populated with a persistent identifier, consumers SHALL NOT expect to be able to resolve the resource and SHALL always use the version of the resource contained in the Bundle to render the composition.
.meta.profile
- used to declare conformance to this profile
- populate with a fixed value:
http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-composition|0.9.1
.meta.versionId
- SHALL be populated by the Patient Summary Repository server
- consuming systems can expect this element to be populated when retrieving patient summary instances from the repository
- source systems do not need to populate this element prior to submission
.text
- text summary of the resource, for human interpretation
.identifier
- the Composition business identifier
- identifier.system SHALL be a URL provided by OH at the time of implementation
- identifier.value may be a generated value such as a UUID
.status
- typically set to "final"
- when invalidating an existing patient summary,
.status
SHALL be set to 'entered-in-error'
.type
.coding
to type of document to consumer systems, where:.system
SHALL be populated with "http://loinc.org".code
SHALL be populated with "60591-5"
Note: Search parameters for base resource include type (token).
.subject
- identifies the person that the Patient Summary is about
- SHALL be populated with a reference to a
Patient
resource included in aBundle.entry
.date
- the datetime when the author 'wrote' the Patient summary
- format: YYYY, YYYY-MM, YYYY-MM-DD or YYYY-MM-DDThh:mm:ss+zz:zz
.author
- identifies the person or system that the Patient Summary was created by
- SHALL be populated with a reference to a
PractitionerRole
resource OR a reference to aDevice
resource included in aBundle.entry
- SHALL include at least one reference to a resource that conforms to the PractitionerRole (PS-ON) profile. Other resource references may also be provided as long as at least one PractitionerRole (PS-ON) is included
- The Author is the Health Care Practitioner who reviews and signs off the Patient Summary composition before it is submitted to the repository. By virtue of signing off the Patient Summary, the Author would also be the Attester, i.e. the individual who attests to the accuracy of the Patient Summary composition. Where a HIC has opted into automated compilation and submission of a Patient Summary by the PoS System, the Author would be the PoS System and the Attester would be the HIC.
.title
- human readable title
- populate with "Ontario Patient Summary"
.confidentiality
- Where there is no explicit restriction applied to the record, set
Composition.confidentiality
to "n". - If the patient's record is classified as private or restricted in the PoS, it shall not be submitted to the Patient Summary repository.
.attester.mode
- if the attester contains only the HIC organization information,
attester.mode
should be set to "official" - if the attester contains the information of both the HIC and health care practitioner,
attester.mode
should be set to "professional"
.attester.time
- the datetime when Patient Summary was attested to
- format: YYYY, YYYY-MM, YYYY-MM-DD or YYYY-MM-DDThh:mm:ss+zz:zz
.attester.party
- SHALL identify the person who attests to accuracy of the Patient Summary (MAY be the author)
- SHALL be populated with a reference to a
PractitionerRole
resource included in aBundle.entry
- The Author is the Health Care Practitioner who reviews and signs off the Patient Summary composition before it is submitted to the repository. By virtue of signing off the Patient Summary, the Author would also be the Attester, i.e. the individual who attests to the accuracy of the Patient Summary composition. Where a HIC has opted into automated compilation and submission of a Patient Summary by the PoS System, the Author would be the PoS System and the Attester would be the HIC.
.custodian
- SHALL identify the "Health Information Custodian" (as that term is defined in PHIPA) that provides the Patient Summary to Ontario Health as a Prescribed Organization for the purposes of the EHR.
- SHALL be populated with a reference to an
Organization
resource included in aBundle.entry
.section
- this element is sliced to represent the different sections of the patient summary
.section.code
contains a LOINC code to convey the section type- all resources referenced in the composition SHALL be contained within the patient summary bundle
.section:sectionMedications
- slice containing the Patient Summary Medication section
.section:sectionMedications.title
- a human readable label for the section, often used in the table of contents
- populate with "Medication Summary"
.section:sectionMedications.code
.coding
to convey the meaning of the section to consumer systems, where:.system
SHALL be populated with "http://loinc.org".code
SHALL be populated with "10160-0"
.section:sectionMedications.text
- a text summary of the section, for human interpretation
.section:sectionMedications.entry
- the
.entry
element with a collection of one or more.reference
to instances of amedicationStatement
ormedicationRequest
resource, where:- active and stopped medications that are clinically relevant and available in the source system(s) SHALL be provided in separate
medicationStatement
ormedicationRequest
resources - a
medicationStatement
resource with.medicationCodeableConcept
SHALL be provided to explicitly state that active medications are known not to be present or are unknown - each
.reference
SHALL reference a FHIR resource contained inBundle.entry
- active and stopped medications that are clinically relevant and available in the source system(s) SHALL be provided in separate
.section:sectionAllergies
- slice containing the Patient Summary Allergies and Intolerances Section
.section:sectionAllergies.title
- a human readable label for the section, often used in the table of contents
- populate with "Allergies and Intolerances"
.section:sectionAllergies.code
.coding
to convey the meaning of the section to consumer systems, where:.system
SHALL be populated with "http://loinc.org".code
SHALL be populated with "48765-2"
.section:sectionAllergies.code
- a text summary of the section, for human interpretation
.section:sectionAllergies.entry
- the
.entry
element with a collection of one or more.reference
to instances of theallergyIntolerance
resource, where:- all active allergies and intolerances available in the source system(s) SHALL be provided in separate
allergyIntolerance
resources - an
allergyIntolerance
with a.code
SHALL be provided to explicitly state that allergies are known not to be present or are unknown - each
.reference
SHALL reference a FHIR resource contained inBundle.entry
- all active allergies and intolerances available in the source system(s) SHALL be provided in separate
.section:sectionProblems
- slice containing the Patient Summary Problems section
.section:sectionProblems.title
- a human readable label for the section, often used in the table of contents
- populate with "Problems"
.section:sectionProblems.code
.coding
to convey the meaning of the section to consumer systems, where:.system
SHALL be populated with "http://loinc.org".code
SHALL be populated with "11450-4"
.section:sectionProblems.code
- a text summary of the section, for human interpretation
.section:sectionProblems.entry
- the
.entry
element with a collection of one or more.reference
to instances of theCondition
resource, where:- all known active problems or conditions available in the source system(s) SHALL be provided in separate
Condition
resources - a
Condition
with a.code
SHALL be provided to explicitly state that allergies are known not to be present or are unknown - each
.reference
SHALL reference a FHIR resource contained inBundle.entry
- all known active problems or conditions available in the source system(s) SHALL be provided in separate
.section:sectionProceduresHx
- slice containing the Patient Summary History of Procedures section
.section:sectionProceduresHx.title
- a human readable label for the section, often used in the table of contents
- populate with "History of Procedures"
.section:sectionProceduresHx.code
.coding
to convey the meaning of the section to consumer systems, where:.system
SHALL be populated with "http://loinc.org".code
SHALL be populated with "47519-4"
.section:sectionProceduresHx.code
- a text summary of the section, for human interpretation
.section:sectionProceduresHx.entry
- the
.entry
element with a collection of one or more.reference
to instances of theProcedure
resource, where:- all available known procedures in the source system(s) SHOULD be provided in separate
Procedure
resources - a
Procedure
with a.code
SHOULD be provided to explicitly state that past procedures are known not to be present or are unknown - each
.reference
SHALL reference a FHIR resource contained inBundle.entry
- all available known procedures in the source system(s) SHOULD be provided in separate
- When the PoS system contains text only for a procedure and cannot distinguish procedure from condition based on code, it is acceptable to include the procedure under the Past History of Illness section
.section:sectionImmunizations
- slice containing the Patient Summary Immunizations Section
.section:sectionImmunizations.title
- a human readable label for the section, often used in the table of contents
- populate with "Immunizations"
.section:sectionImmunizations.code
.coding
to convey the meaning of the section to consumer systems, where:.system
SHALL be populated with "http://loinc.org".code
SHALL be populated with "11369-6"
.section:sectionImmunizations.code
- a text summary of the section, for human interpretation
.section:sectionImmunizations.entry
- the
.entry
element with a collection of one or more.reference
to instances of theImmunization
resource, where:- all known and available immunizations in the source system(s) SHOULD be provided in separate
Immunization
resources - an
Immunization
with a.code
SHOULD be provided to explicitly state that immunizations are known not to be present or are unknown - each
.reference
SHALL reference a FHIR resource contained inBundle.entry
- all known and available immunizations in the source system(s) SHOULD be provided in separate
.section:sectionPastIllnessHx
- slice containing the Patient Summary History of Past Illness Section section
.section:sectionPastIllnessHx.title
- a human readable label for the section, often used in the table of contents
- populate with "History of Past Illness"
.section:sectionPastIllnessHx.code
.coding
to convey the meaning of the section to consumer systems, where:.system
SHALL be populated with "http://loinc.org".code
SHALL be populated with "11348-0"
.section:sectionPastIllnessHx.code
- a text summary of the section, for human interpretation
.section:sectionPastIllnessHx.entry
- the
.entry
element with a collection of one or more.reference
to instances of theCondition
resource, where:- all known available past conditions in the source system(s) SHOULD be provided in separate
Condition
resources - a
Condition
with a.code
SHOULD be provided to explicitly state that past conditions a known not to be present or are unknown - each
.reference
SHALL reference a FHIR resource contained inBundle.entry
- all known available past conditions in the source system(s) SHOULD be provided in separate
- When the PoS system contains text only for a procedure and cannot distinguish procedure from condition based on code, it is acceptable to include the procedure under the Past History of Illness section