Send ClinicalReportResearch
Introduction
This page describes the technical specification of the use case: Send ClinicalReportResearch.
Security considerations
This guide assumes that client and server are able to make a secure connection. It does not provide information on finding the right server nor does it provide information about security. Moreover, each transaction is performed in the context of a specific authenticated/authorized patient, for whose context (token) has been established using authentication mechanisms described elsewhere. Each actor is required to filter out all the records that are not associated with the authenticated patient.
Send ClinicalReportResearch by the Provider
The ClinicalReportResearch (CRR) is sent as a FHIR Document. A document is a FHIR Bundle that assembles all relevant resources that need to be exchanged, together with a Composition resource that summarizes and references all these resources. This allows to include referenced secondary resources too. The interaction is performed by an HTTP POST command as shown:
POST [fhir base url]/Bundle
The body of the POST submission is a Bundle that has Bundle.type
= document and contains a globally unique Bundle.identifier
for this instance of the CRR message and is never re-used. The first Bundle.entry
is the ClinicalReportResearch-Composition. At least the Patient and one or more clincal related resources are expected to be included as well.
The Provider SHALL guarantee consistency of all FHIR resource elements with the requirements specified in the FHIR-profiles referenced from the Composition profile or from the referenced profiles. This page provides an overview of FHIR profiles in the CRR and links to the profile pages in the CBB implementation guide.
Composition
The Composition is structured using sections, each with its own fixed code (.section.code
) that is added to the Composition resource instance. The sections and codes are aligned with sections in the International Patient Summary (IPS). The administrativeData and encounter sections do not exist in the IPS and are coded separately.
Composition | I | Composition | There are no (further) constraints on this element Element IdComposition A set of resources composed into a single coherent clinical statement with clinical attestation DefinitionA set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). 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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identifier | Σ | 0..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 | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element 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 composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. The workflow/clinical status of the composition. CompositionStatus (required)Constraints
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type | Σ | 1..1 | CodeableConceptBinding | Element IdComposition.type Kind of composition (LOINC if possible) DefinitionSpecifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. 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 | Σ I | 1..1 | Reference(Patient | HdBe Patient) | Element IdComposition.subject Who and/or what the composition is about DefinitionWho or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). 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. Reference(Patient | HdBe Patient) Constraints
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encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element 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. 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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date | 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 | Σ I | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization Organization) | Element IdComposition.author Who and/or what authored the composition DefinitionIdentifies who is responsible for the information in the composition, 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 | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization Organization) Constraints
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title | Σ | 1..1 | string | There are no (further) constraints on this element Element IdComposition.title Human Readable name/title DefinitionOfficial human-readable label for the composition. 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 | 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 | 0..* | 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 | 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 | 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 | I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element 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(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Constraints
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custodian | Σ I | 0..1 | Reference(Organization | HdBe HealthcareOrganization Organization) | 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 | HdBe HealthcareOrganization Organization) Constraints
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relatesTo | 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 | 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] | 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 | Data Type | ||
targetReference | Reference(Composition | HdBe ClinicalReport for Research Composition) | Data Type Reference(Composition | HdBe ClinicalReport for Research Composition) | ||
event | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdComposition.event The clinical service(s) being documented DefinitionThe clinical service, such as a colonoscopy or an appendectomy, being 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 | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element 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.ActCode (example)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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section | I | 0..* | BackboneElement | Element IdComposition.section Composition is broken into sections DefinitionThe root of the sections that make up the 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 | 1..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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administrativeData | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:administrativeData Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:administrativeData.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 | 1..1 | CodeableConcept | Element IdComposition.section:administrativeData.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://snomed.info/sct", "code": "405624007" } ] }
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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:administrativeData.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:administrativeData.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:administrativeData.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:administrativeData.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:administrativeData.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(HdBe ContactPerson | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization | HdBe HealthcareOrganization Organization) | Element IdComposition.section:administrativeData.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. Reference(HdBe ContactPerson | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization | HdBe HealthcareOrganization Organization) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:administrativeData.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:administrativeData.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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medication | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:medication Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:medication.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 | 1..1 | CodeableConcept | Element IdComposition.section:medication.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:medication.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:medication.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:medication.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:medication.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:medication.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(HdBe MedicationAdministration2 | HdBe MedicationAgreement | HdBe MedicationUse2) | Element IdComposition.section:medication.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. Reference(HdBe MedicationAdministration2 | HdBe MedicationAgreement | HdBe MedicationUse2) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:medication.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:medication.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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allergies | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:allergies Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:allergies.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 | 1..1 | CodeableConcept | Element IdComposition.section:allergies.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:allergies.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:allergies.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:allergies.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:allergies.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:allergies.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(HdBe AllergyIntolerance) | Element IdComposition.section:allergies.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. Reference(HdBe AllergyIntolerance) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:allergies.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:allergies.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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problems | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:problems Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:problems.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 | 1..1 | CodeableConcept | Element IdComposition.section:problems.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:problems.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:problems.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:problems.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:problems.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:problems.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(HdBe Problem) | Element IdComposition.section:problems.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:problems.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:problems.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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procedures | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:procedures Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:procedures.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 | 1..1 | CodeableConcept | Element IdComposition.section:procedures.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:procedures.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:procedures.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:procedures.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:procedures.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:procedures.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(HdBe Procedure event | HdBe Procedure request) | Element IdComposition.section:procedures.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. Reference(HdBe Procedure event | HdBe Procedure request) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:procedures.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:procedures.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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immunizations | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:immunizations Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:immunizations.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 | 1..1 | CodeableConcept | Element IdComposition.section:immunizations.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:immunizations.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:immunizations.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:immunizations.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:immunizations.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:immunizations.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(HdBe Vaccination event) | Element IdComposition.section:immunizations.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. Reference(HdBe Vaccination event) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:immunizations.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:immunizations.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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medicalDevices | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:medicalDevices Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:medicalDevices.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 | 1..1 | CodeableConcept | Element IdComposition.section:medicalDevices.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": "46264-8" } ] }
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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:medicalDevices.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:medicalDevices.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:medicalDevices.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:medicalDevices.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:medicalDevices.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(HdBe MedicalDevice | HdBe MedicalDevice.Product) | Element IdComposition.section:medicalDevices.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. Reference(HdBe MedicalDevice | HdBe MedicalDevice.Product) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:medicalDevices.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:medicalDevices.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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vitalSigns | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:vitalSigns Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:vitalSigns.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 | 1..1 | CodeableConcept | Element IdComposition.section:vitalSigns.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": "8716-3" } ] }
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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:vitalSigns.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:vitalSigns.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:vitalSigns.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:vitalSigns.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:vitalSigns.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(HdBe BloodPressure | HdBe BodyHeight | HdBe BodyTemperature | HdBe BodyWeight) | Element IdComposition.section:vitalSigns.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. Reference(HdBe BloodPressure | HdBe BodyHeight | HdBe BodyTemperature | HdBe BodyWeight) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:vitalSigns.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:vitalSigns.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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functionalStatus | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:functionalStatus Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:functionalStatus.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 | 1..1 | CodeableConcept | Element IdComposition.section:functionalStatus.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": "47420-5" } ] }
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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:functionalStatus.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:functionalStatus.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:functionalStatus.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:functionalStatus.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:functionalStatus.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(HdBe FunctionalOrMentalStatus | HdBe HearingFunction | HdBe HearingFunction.HearingAid | HdBe HearingFunction.HearingAid.Product | HdBe VisualFunction.VisualAid.Product | HdBe VisualFunction.VisualAid | HdBe VisualFunction) | Element IdComposition.section:functionalStatus.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. Reference(HdBe FunctionalOrMentalStatus | HdBe HearingFunction | HdBe HearingFunction.HearingAid | HdBe HearingFunction.HearingAid.Product | HdBe VisualFunction.VisualAid.Product | HdBe VisualFunction.VisualAid | HdBe VisualFunction) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:functionalStatus.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:functionalStatus.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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socialHistory | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:socialHistory Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:socialHistory.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 | 1..1 | CodeableConcept | Element IdComposition.section:socialHistory.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": "29762-2" } ] }
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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:socialHistory.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:socialHistory.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:socialHistory.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:socialHistory.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:socialHistory.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(HdBe SmokingStatus) | Element IdComposition.section:socialHistory.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:socialHistory.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:socialHistory.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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encounters | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:encounters Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:encounters.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 | 1..1 | CodeableConcept | Element IdComposition.section:encounters.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://snomed.info/sct", "code": "371531000" } ] }
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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:encounters.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:encounters.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:encounters.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:encounters.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:encounters.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(HdBe Encounter) | Element IdComposition.section:encounters.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:encounters.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:encounters.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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Composition | I | Composition | There are no (further) constraints on this element Element IdComposition A set of resources composed into a single coherent clinical statement with clinical attestation DefinitionA set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). 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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identifier | Σ | 0..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 | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element 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 composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. The workflow/clinical status of the composition. CompositionStatus (required)Constraints
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type | Σ | 1..1 | CodeableConceptBinding | Element IdComposition.type Kind of composition (LOINC if possible) DefinitionSpecifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. 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 | Σ I | 1..1 | Reference(Patient | HdBe Patient) | Element IdComposition.subject Who and/or what the composition is about DefinitionWho or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). 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. Reference(Patient | HdBe Patient) Constraints
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encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element 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. 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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date | 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 | Σ I | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization Organization) | Element IdComposition.author Who and/or what authored the composition DefinitionIdentifies who is responsible for the information in the composition, 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 | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization Organization) Constraints
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title | Σ | 1..1 | string | There are no (further) constraints on this element Element IdComposition.title Human Readable name/title DefinitionOfficial human-readable label for the composition. 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 | 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 | 0..* | 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 | 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 | 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 | I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element 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(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Constraints
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custodian | Σ I | 0..1 | Reference(Organization | HdBe HealthcareOrganization Organization) | 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 | HdBe HealthcareOrganization Organization) Constraints
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relatesTo | 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 | 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] | 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 | Data Type | ||
targetReference | Reference(Composition | HdBe ClinicalReport for Research Composition) | Data Type Reference(Composition | HdBe ClinicalReport for Research Composition) | ||
event | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdComposition.event The clinical service(s) being documented DefinitionThe clinical service, such as a colonoscopy or an appendectomy, being 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 | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element 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.ActCode (example)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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section | I | 0..* | BackboneElement | Element IdComposition.section Composition is broken into sections DefinitionThe root of the sections that make up the 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 | 1..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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administrativeData | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:administrativeData Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:administrativeData.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 | 1..1 | CodeableConcept | Element IdComposition.section:administrativeData.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://snomed.info/sct", "code": "405624007" } ] }
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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:administrativeData.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:administrativeData.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:administrativeData.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:administrativeData.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:administrativeData.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(HdBe ContactPerson | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization | HdBe HealthcareOrganization Organization) | Element IdComposition.section:administrativeData.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. Reference(HdBe ContactPerson | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization | HdBe HealthcareOrganization Organization) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:administrativeData.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:administrativeData.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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medication | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:medication Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:medication.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 | 1..1 | CodeableConcept | Element IdComposition.section:medication.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:medication.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:medication.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:medication.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:medication.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:medication.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(HdBe MedicationAdministration2 | HdBe MedicationAgreement | HdBe MedicationUse2) | Element IdComposition.section:medication.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. Reference(HdBe MedicationAdministration2 | HdBe MedicationAgreement | HdBe MedicationUse2) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:medication.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:medication.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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allergies | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:allergies Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:allergies.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 | 1..1 | CodeableConcept | Element IdComposition.section:allergies.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:allergies.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:allergies.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:allergies.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:allergies.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:allergies.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(HdBe AllergyIntolerance) | Element IdComposition.section:allergies.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. Reference(HdBe AllergyIntolerance) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:allergies.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:allergies.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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problems | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:problems Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:problems.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 | 1..1 | CodeableConcept | Element IdComposition.section:problems.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:problems.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:problems.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:problems.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:problems.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:problems.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(HdBe Problem) | Element IdComposition.section:problems.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:problems.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:problems.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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procedures | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:procedures Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:procedures.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 | 1..1 | CodeableConcept | Element IdComposition.section:procedures.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:procedures.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:procedures.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:procedures.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:procedures.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:procedures.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(HdBe Procedure event | HdBe Procedure request) | Element IdComposition.section:procedures.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. Reference(HdBe Procedure event | HdBe Procedure request) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:procedures.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:procedures.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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immunizations | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:immunizations Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:immunizations.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 | 1..1 | CodeableConcept | Element IdComposition.section:immunizations.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:immunizations.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:immunizations.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:immunizations.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:immunizations.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:immunizations.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(HdBe Vaccination event) | Element IdComposition.section:immunizations.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. Reference(HdBe Vaccination event) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:immunizations.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:immunizations.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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medicalDevices | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:medicalDevices Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:medicalDevices.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 | 1..1 | CodeableConcept | Element IdComposition.section:medicalDevices.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": "46264-8" } ] }
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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:medicalDevices.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:medicalDevices.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:medicalDevices.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:medicalDevices.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:medicalDevices.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(HdBe MedicalDevice | HdBe MedicalDevice.Product) | Element IdComposition.section:medicalDevices.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. Reference(HdBe MedicalDevice | HdBe MedicalDevice.Product) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:medicalDevices.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:medicalDevices.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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vitalSigns | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:vitalSigns Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:vitalSigns.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 | 1..1 | CodeableConcept | Element IdComposition.section:vitalSigns.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": "8716-3" } ] }
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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:vitalSigns.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:vitalSigns.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:vitalSigns.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:vitalSigns.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:vitalSigns.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(HdBe BloodPressure | HdBe BodyHeight | HdBe BodyTemperature | HdBe BodyWeight) | Element IdComposition.section:vitalSigns.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. Reference(HdBe BloodPressure | HdBe BodyHeight | HdBe BodyTemperature | HdBe BodyWeight) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:vitalSigns.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:vitalSigns.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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functionalStatus | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:functionalStatus Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:functionalStatus.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 | 1..1 | CodeableConcept | Element IdComposition.section:functionalStatus.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": "47420-5" } ] }
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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:functionalStatus.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:functionalStatus.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:functionalStatus.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:functionalStatus.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:functionalStatus.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(HdBe FunctionalOrMentalStatus | HdBe HearingFunction | HdBe HearingFunction.HearingAid | HdBe HearingFunction.HearingAid.Product | HdBe VisualFunction.VisualAid.Product | HdBe VisualFunction.VisualAid | HdBe VisualFunction) | Element IdComposition.section:functionalStatus.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. Reference(HdBe FunctionalOrMentalStatus | HdBe HearingFunction | HdBe HearingFunction.HearingAid | HdBe HearingFunction.HearingAid.Product | HdBe VisualFunction.VisualAid.Product | HdBe VisualFunction.VisualAid | HdBe VisualFunction) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:functionalStatus.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:functionalStatus.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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socialHistory | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:socialHistory Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:socialHistory.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 | 1..1 | CodeableConcept | Element IdComposition.section:socialHistory.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": "29762-2" } ] }
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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:socialHistory.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:socialHistory.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:socialHistory.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:socialHistory.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:socialHistory.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(HdBe SmokingStatus) | Element IdComposition.section:socialHistory.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:socialHistory.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:socialHistory.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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encounters | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:encounters Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:encounters.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 | 1..1 | CodeableConcept | Element IdComposition.section:encounters.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://snomed.info/sct", "code": "371531000" } ] }
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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:encounters.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:encounters.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:encounters.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:encounters.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:encounters.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(HdBe Encounter) | Element IdComposition.section:encounters.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:encounters.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:encounters.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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Composition | I | Composition | There are no (further) constraints on this element Element IdComposition A set of resources composed into a single coherent clinical statement with clinical attestation DefinitionA set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). 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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identifier | Σ | 0..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 | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element 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 composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. The workflow/clinical status of the composition. CompositionStatus (required)Constraints
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type | Σ | 1..1 | CodeableConceptBinding | Element IdComposition.type Kind of composition (LOINC if possible) DefinitionSpecifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. 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 | Σ I | 1..1 | Reference(Patient | HdBe Patient) | Element IdComposition.subject Who and/or what the composition is about DefinitionWho or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). 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. Reference(Patient | HdBe Patient) Constraints
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encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element 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. 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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date | 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 | Σ I | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization Organization) | Element IdComposition.author Who and/or what authored the composition DefinitionIdentifies who is responsible for the information in the composition, 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 | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization Organization) Constraints
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title | Σ | 1..1 | string | There are no (further) constraints on this element Element IdComposition.title Human Readable name/title DefinitionOfficial human-readable label for the composition. 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 | 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 | 0..* | 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 | 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 | 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 | I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element 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(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Constraints
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custodian | Σ I | 0..1 | Reference(Organization | HdBe HealthcareOrganization Organization) | 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 | HdBe HealthcareOrganization Organization) Constraints
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relatesTo | 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 | 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] | 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 | Data Type | ||
targetReference | Reference(Composition | HdBe ClinicalReport for Research Composition) | Data Type Reference(Composition | HdBe ClinicalReport for Research Composition) | ||
event | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdComposition.event The clinical service(s) being documented DefinitionThe clinical service, such as a colonoscopy or an appendectomy, being 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 | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element 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.ActCode (example)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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section | I | 0..* | BackboneElement | Element IdComposition.section Composition is broken into sections DefinitionThe root of the sections that make up the 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 | 1..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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administrativeData | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:administrativeData Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:administrativeData.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 | 1..1 | CodeableConcept | Element IdComposition.section:administrativeData.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://snomed.info/sct", "code": "405624007" } ] }
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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:administrativeData.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:administrativeData.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:administrativeData.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:administrativeData.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:administrativeData.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(HdBe ContactPerson | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization | HdBe HealthcareOrganization Organization) | Element IdComposition.section:administrativeData.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. Reference(HdBe ContactPerson | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization | HdBe HealthcareOrganization Organization) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:administrativeData.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:administrativeData.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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medication | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:medication Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:medication.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 | 1..1 | CodeableConcept | Element IdComposition.section:medication.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:medication.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:medication.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:medication.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:medication.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:medication.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(HdBe MedicationAdministration2 | HdBe MedicationAgreement | HdBe MedicationUse2) | Element IdComposition.section:medication.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. Reference(HdBe MedicationAdministration2 | HdBe MedicationAgreement | HdBe MedicationUse2) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:medication.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:medication.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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allergies | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:allergies Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:allergies.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 | 1..1 | CodeableConcept | Element IdComposition.section:allergies.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:allergies.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:allergies.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:allergies.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:allergies.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:allergies.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(HdBe AllergyIntolerance) | Element IdComposition.section:allergies.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. Reference(HdBe AllergyIntolerance) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:allergies.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:allergies.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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problems | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:problems Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:problems.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 | 1..1 | CodeableConcept | Element IdComposition.section:problems.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:problems.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:problems.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:problems.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:problems.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:problems.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(HdBe Problem) | Element IdComposition.section:problems.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:problems.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:problems.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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procedures | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:procedures Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:procedures.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 | 1..1 | CodeableConcept | Element IdComposition.section:procedures.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:procedures.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:procedures.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:procedures.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:procedures.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:procedures.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(HdBe Procedure event | HdBe Procedure request) | Element IdComposition.section:procedures.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. Reference(HdBe Procedure event | HdBe Procedure request) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:procedures.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:procedures.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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immunizations | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:immunizations Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:immunizations.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 | 1..1 | CodeableConcept | Element IdComposition.section:immunizations.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:immunizations.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:immunizations.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:immunizations.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:immunizations.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:immunizations.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(HdBe Vaccination event) | Element IdComposition.section:immunizations.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. Reference(HdBe Vaccination event) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:immunizations.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:immunizations.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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medicalDevices | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:medicalDevices Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:medicalDevices.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 | 1..1 | CodeableConcept | Element IdComposition.section:medicalDevices.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": "46264-8" } ] }
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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:medicalDevices.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:medicalDevices.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:medicalDevices.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:medicalDevices.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:medicalDevices.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(HdBe MedicalDevice | HdBe MedicalDevice.Product) | Element IdComposition.section:medicalDevices.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. Reference(HdBe MedicalDevice | HdBe MedicalDevice.Product) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:medicalDevices.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:medicalDevices.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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vitalSigns | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:vitalSigns Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:vitalSigns.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 | 1..1 | CodeableConcept | Element IdComposition.section:vitalSigns.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": "8716-3" } ] }
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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:vitalSigns.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:vitalSigns.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:vitalSigns.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:vitalSigns.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:vitalSigns.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(HdBe BloodPressure | HdBe BodyHeight | HdBe BodyTemperature | HdBe BodyWeight) | Element IdComposition.section:vitalSigns.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. Reference(HdBe BloodPressure | HdBe BodyHeight | HdBe BodyTemperature | HdBe BodyWeight) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:vitalSigns.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:vitalSigns.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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functionalStatus | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:functionalStatus Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:functionalStatus.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 | 1..1 | CodeableConcept | Element IdComposition.section:functionalStatus.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": "47420-5" } ] }
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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:functionalStatus.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:functionalStatus.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:functionalStatus.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:functionalStatus.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:functionalStatus.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(HdBe FunctionalOrMentalStatus | HdBe HearingFunction | HdBe HearingFunction.HearingAid | HdBe HearingFunction.HearingAid.Product | HdBe VisualFunction.VisualAid.Product | HdBe VisualFunction.VisualAid | HdBe VisualFunction) | Element IdComposition.section:functionalStatus.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. Reference(HdBe FunctionalOrMentalStatus | HdBe HearingFunction | HdBe HearingFunction.HearingAid | HdBe HearingFunction.HearingAid.Product | HdBe VisualFunction.VisualAid.Product | HdBe VisualFunction.VisualAid | HdBe VisualFunction) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdComposition.section:functionalStatus.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:functionalStatus.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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socialHistory | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:socialHistory Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:socialHistory.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 | 1..1 | CodeableConcept | Element IdComposition.section:socialHistory.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": "29762-2" } ] }
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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:socialHistory.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:socialHistory.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:socialHistory.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:socialHistory.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:socialHistory.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(HdBe SmokingStatus) | Element IdComposition.section:socialHistory.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:socialHistory.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:socialHistory.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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encounters | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdComposition.section:encounters Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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title | 0..1 | string | There are no (further) constraints on this element Element IdComposition.section:encounters.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 | 1..1 | CodeableConcept | Element IdComposition.section:encounters.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://snomed.info/sct", "code": "371531000" } ] }
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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:encounters.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:encounters.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:encounters.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:encounters.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:encounters.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(HdBe Encounter) | Element IdComposition.section:encounters.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:encounters.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:encounters.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.
|
Section | CodeSystem | CodeValue |
---|---|---|
administrativeData | http://snomed.info/sct | 405624007 |
medication | http://loinc.org | 10160-0 |
allergies | http://loinc.org | 48765-2 |
problems | http://loinc.org | 11450-4 |
procedures | http://loinc.org | 47519-4 |
immunizations | http://loinc.org | 11369-6 |
medicalDevices | http://loinc.org | 46264-8 |
vitalSigns | http://loinc.org | 8716-3 |
functionalStatus | http://loinc.org | 47420-5 |
socialHistory | http://loinc.org | 29762-2 |
encounters | http://snomed.info/sct | 371531000 |
Resource references
The Provider system SHALL produce a complete Bundle containing not only the resources listed directly in the Composition, but all the indirectly referenced resources (such as PharmaceuticalProduct referenced by MedicationAgreement) as well. This should prevent the receiving system to resolve references at the sending system. The CBB implementation guide provides additional guidance on the use of the reference data type.
Identification
Resources SHALL have a stable identifier in the .identifier
element for all resources if such an identifier exists in the underlying data. Not all data, like individual results, are currently known to have identifiers in all source systems, but when they exist they are essential and where they do not exist yet they SHOULD be considered. Having stable identification is essential in detection of duplicates. For more information on dealing with identifiers, see the CBB implementation guide.
Examples
Receive ClinicalReportResearch by the Consumer
The document Bundle should be processed as a transaction by the Consumer. The Consumer response shall be sent when a success or error condition needs to be communicated. Success is only indicated once the Bundle and accompanying resources are received and completely processed and persisted as appropriate to the Consumer configuration. The Consumer returns an HTTP Status code appropriate to the processing outcome.
Usage in DCDs
Generally, DCDs require parts of a CRR. Moreover, they can also require additional data elements. This is supported by this Composition profile, based on the following defined implementation rules:
- A derived ClinicalReportResearch-Composition profile is created that specifies the information requirements.
- The
title
of the Composition SHALL match the name of the DCD. - Additional sections are added for each segment of a DCD that is missing in the CRR, designated with a meaningful code in
.section.code
.