Composition PT PS
| 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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| id | Σ | 1..1 | id | There are no (further) constraints on this element Element idComposition.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
| meta | Σ | 0..1 | Meta PT Core | There are no (further) constraints on this element Element idComposition.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idComposition.implicitRules A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). IETF language tag
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| text | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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| contained | I | 0..0 | Resource | There are no (further) constraints on this element Element idComposition.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| identifier | Σ | 0..1 | Extension Identifier PT Core | There are no (further) constraints on this element Element idComposition.identifier An identifier intended for computation DefinitionIdentificador da composição/documento por parte do negócio Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.
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| status | Σ ?! | 1..1 | codeBinding | Element idComposition.status preliminary | final | amended | entered-in-error DefinitionIdentifica o status da composição/documento. 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.
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| type | Σ | 1..1 | CodeableConcept PT CoreBinding | Element idComposition.type Concept - reference to a terminology or just text DefinitionTipo de composição/documento. Key metadata element describing the composition, used in searching/filtering. Value Set Name: DocumentType Type of a composition.
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| id | 0..1 | id | There are no (further) constraints on this element Element idComposition.type.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.type.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ | 0..* | Coding PT Core | There are no (further) constraints on this element Element idComposition.type.coding A reference to a code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information.
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| id | 0..1 | id | There are no (further) constraints on this element Element idComposition.type.coding.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.type.coding.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.type.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://loinc.org
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| version | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.type.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | codeFixed Value | Element idComposition.type.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
60591-5
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| display | Σ | 1..1 | stringFixed Value | Element idComposition.type.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
Patient summary Document
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.type.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 1..1 | stringFixed Value | Element idComposition.type.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
Resumo de saúde do utente
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| category | Σ | 0..0 | CodeableConcept PT Core | There are no (further) constraints on this element Element idComposition.category Concept - reference to a terminology or just text DefinitionCategoria No caso de referenciação, transferência ou requisição identificar a categoria, de acordo com o catálogo CPARADM, ValueSet Service Request Category, codificado em SNOMED CT (“http://snomed.info/sct”). Esta categoria irá permitir a distinção do pedido efetuado. O catálogo pode ser solicitado ao https://www.ctc.min-saude.pt/ Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. High-level kind of a clinical document at a macro level.
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| subject | Σ I | 1..1 | Reference(Patient PT PS) | Element idComposition.subject Who and/or what the composition is about DefinitionSobre quem ou o que é a composição ou documento. Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. For clinical documents, this is usually the patient.
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| encounter | Σ I | 0..0 | Reference(Encounter PT Core) | There are no (further) constraints on this element Element idComposition.encounter Context of the Composition DefinitionEpisódio 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 | Element idComposition.date Composition editing time DefinitionData da composição/documento. 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 PT PS | PractitionerRole PT PS | Organization PT PS) | Element idComposition.author Who and/or what authored the composition DefinitionResponsável pela criação do documento 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 PT PS | PractitionerRole PT PS | Organization PT PS) Constraints
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| title | Σ | 1..1 | stringFixed Value | Element idComposition.title Human Readable name/title DefinitionTítulo do documento. 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.
Resumo de Saúde do Utente
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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 DefinitionNível de confidencialidade do documento 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.
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| attester | 0..0 | BackboneElement | There are no (further) constraints on this element Element idComposition.attester Attests to accuracy of composition DefinitionIdentifica a responsabilidade pela precisão do conteúdo da composição/documento. Identifies responsibility for the accuracy of the composition content. Only list each attester once.
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| custodian | Σ I | 0..0 | Reference(Organization PT PS) | Element idComposition.custodian Organization which maintains the composition DefinitionEntidade responsável pela composição/documento 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.
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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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| id | 0..1 | id | There are no (further) constraints on this element Element idComposition.relatesTo.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.relatesTo.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.relatesTo.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| code | 1..1 | codeBinding | There are no (further) constraints on this element Element idComposition.relatesTo.code replaces | transforms | signs | appends DefinitionIndica o tipo de relação que esta composição tem com outra composição ou documento 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.
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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 DefinitionComposição/documento de destino desse relacionamento.
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| targetIdentifier | Extension Identifier PT Core | Data type | ||
| targetReference | Reference(Composition PT PS) | Data type | ||
| event | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idComposition.event The clinical service(s) being documented DefinitionIndica o serviço documentado 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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| id | 0..1 | id | There are no (further) constraints on this element Element idComposition.event.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.event.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.event.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| code | Σ | 0..* | CodeableConcept PT Core | There are no (further) constraints on this element Element idComposition.event.code Concept - reference to a terminology or just text DefinitionRepresenta os principais atos clínicos. Usar o system http://terminology.hl7.org/CodeSystem/v3-ActCode Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. This list of codes represents the main clinical acts being documented.
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| id | 0..1 | id | There are no (further) constraints on this element Element idComposition.event.code.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.event.code.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ | 0..* | Coding PT Core | There are no (further) constraints on this element Element idComposition.event.code.coding A reference to a code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information.
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| id | 0..1 | id | There are no (further) constraints on this element Element idComposition.event.code.coding.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.event.code.coding.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.event.code.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://terminology.hl7.org/CodeSystem/v3-ActClass
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| version | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.event.code.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | codeFixed Value | Element idComposition.event.code.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
PCPR
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| display | Σ | 1..1 | stringFixed Value | Element idComposition.event.code.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
care provision
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.event.code.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 1..1 | stringFixed Value | Element idComposition.event.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
Prestação de Cuidados
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| period | Σ I | 0..1 | Period PT Core | There are no (further) constraints on this element Element idComposition.event.period Time range defined by start and end date/time Alternate namesPeriod DefinitionPeríodo O período adota o formato definido pela ISO8601 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 DefinitionReferência do(s) evento(s) que está(ão) sendo documentado(s). 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 id(Value) Constraints
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| (All Slices) | There are no (further) constraints on this element | |||
| id | 0..1 | id | There are no (further) constraints on this element Element idComposition.section.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| title | 0..1 | string | There are no (further) constraints on this element Element idComposition.section.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionTítulo da secção Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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| code | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idComposition.section.code Classification of section (recommended) DefinitionIdentifica o tipo de conteúdo presente na secção 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.
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| author | I | 0..* | Reference(Practitioner PT Core | PractitionerRole PT Core | Device PT Core | Patient PT Core | Related Person PT Core | Organization PT Core) | There are no (further) constraints on this element Element idComposition.section.author Who and/or what authored the section DefinitionIndica o responsável pelas informações nesta secção, não necessariamente quem as digitou. 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 PT Core | PractitionerRole PT Core | Device PT Core | Patient PT Core | Related Person PT Core | Organization PT Core) 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 DefinitionO foco real da secção quando esta não é o mesmo assunto da composição 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 DefinitionUma narrativa que contém o conteúdo da secção 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 DefinitionComo a lista foi preparada 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.
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| orderedBy | 0..1 | CodeableConcept PT CoreBinding | There are no (further) constraints on this element Element idComposition.section.orderedBy Concept - reference to a terminology or just text DefinitionEspecifica a ordem aplicada aos itens nas entradas da secção. Usar o system http://terminology.hl7.org/CodeSystem/list-order Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. What order applies to the items in the entry.
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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 DefinitionReferência aos recursos que suportam esta secção If there are no entries in the list, an emptyReason SHOULD be provided.
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| emptyReason | I | 0..1 | CodeableConcept PT CoreBinding | There are no (further) constraints on this element Element idComposition.section.emptyReason Concept - reference to a terminology or just text DefinitionIndica o motivo pelo qual a secção está vazia Usar o system ttp://terminology.hl7.org/CodeSystem/list-empty-reason Allows capturing things like "none exist" or "not asked" which can be important for most lists. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. If a section is empty, why it is empty.
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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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| sectionAllergies | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idComposition.section:sectionAllergies Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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| id | 0..1 | idFixed Value | Element idComposition.section:sectionAllergies.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. sectionAllergies
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| title | 0..1 | stringFixed Value | Element idComposition.section:sectionAllergies.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionTítulo da secção 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.
Secção de Alergias e Reações Adversas
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| code | 0..1 | CodeableConcept PT CoreBinding | Element idComposition.section:sectionAllergies.code Concept - reference to a terminology or just text DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. Provides computable standardized labels to topics within the document. Value Set Name: PatientSummarySection Classification of a section of a composition/document.
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| id | 0..1 | id | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.code.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.code.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ | 0..* | Coding PT Core | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.code.coding A reference to a code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information.
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| id | 0..1 | id | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.code.coding.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.code.coding.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriPattern | Element idComposition.section:sectionAllergies.code.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://loinc.org
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| version | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.code.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | codePattern | Element idComposition.section:sectionAllergies.code.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
48765-2
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| display | Σ | 1..1 | stringPattern | Element idComposition.section:sectionAllergies.code.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
Allergies and adverse reactions document
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.code.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 1..1 | stringPattern | Element idComposition.section:sectionAllergies.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
Secção alergias e reacções adversas
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| author | I | 0..0 | Reference(Practitioner PT Core | PractitionerRole PT Core | Device PT Core | Patient PT Core | Related Person PT Core | Organization PT Core) | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.author Who and/or what authored the section DefinitionIndica o responsável pelas informações nesta secção, não necessariamente quem as digitou. 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 PT Core | PractitionerRole PT Core | Device PT Core | Patient PT Core | Related Person PT Core | Organization PT Core) Constraints
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| focus | I | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.focus Who/what the section is about, when it is not about the subject of composition DefinitionO foco real da secção quando esta não é o mesmo assunto da composição 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:sectionAllergies.text Text summary of the section, for human interpretation DefinitionUma narrativa que contém o conteúdo da secção Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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| mode | 0..0 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.mode working | snapshot | changes DefinitionComo a lista foi preparada 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.
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| orderedBy | 0..0 | CodeableConcept PT CoreBinding | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.orderedBy Concept - reference to a terminology or just text DefinitionEspecifica a ordem aplicada aos itens nas entradas da secção. Usar o system http://terminology.hl7.org/CodeSystem/list-order Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. What order applies to the items in the entry.
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| entry | I | 0..* | Reference(List PT PS) | Element idComposition.section:sectionAllergies.entry A reference to data that supports this section DefinitionReferência aos recursos que suportam esta secção If there are no entries in the list, an emptyReason SHOULD be provided.
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| emptyReason | I | 0..1 | CodeableConcept PT CoreBinding | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.emptyReason Concept - reference to a terminology or just text DefinitionIndica o motivo pelo qual a secção está vazia Usar o system ttp://terminology.hl7.org/CodeSystem/list-empty-reason Allows capturing things like "none exist" or "not asked" which can be important for most lists. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. If a section is empty, why it is empty.
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| section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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| sectionImmunizations | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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| id | 0..1 | idFixed Value | Element idComposition.section:sectionImmunizations.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. sectionImmunizations
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| title | 0..1 | stringFixed Value | Element idComposition.section:sectionImmunizations.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionTítulo da secção 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.
Histórico de vacinação
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| code | 0..1 | CodeableConcept PT CoreBinding | Element idComposition.section:sectionImmunizations.code Concept - reference to a terminology or just text DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. Provides computable standardized labels to topics within the document. Value Set Name: PatientSummarySection Classification of a section of a composition/document.
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| id | 0..1 | id | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.code.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.code.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ | 0..* | Coding PT CorePattern | Element idComposition.section:sectionImmunizations.code.coding A reference to a code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information.
{
"code": "11369-6",
"display": "History of Immunization Narrative"
}
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| id | 0..1 | id | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.code.coding.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.code.coding.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriPattern | Element idComposition.section:sectionImmunizations.code.coding.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://loinc.org
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| version | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.code.coding.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | codePattern | Element idComposition.section:sectionImmunizations.code.coding.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
11369-6
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| display | Σ | 1..1 | stringPattern | Element idComposition.section:sectionImmunizations.code.coding.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
History of Immunization Narrative
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.code.coding.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 1..1 | stringPattern | Element idComposition.section:sectionImmunizations.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
Histórico de imunização
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| author | I | 0..0 | Reference(Practitioner PT Core | PractitionerRole PT Core | Device PT Core | Patient PT Core | Related Person PT Core | Organization PT Core) | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.author Who and/or what authored the section DefinitionIndica o responsável pelas informações nesta secção, não necessariamente quem as digitou. 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 PT Core | PractitionerRole PT Core | Device PT Core | Patient PT Core | Related Person PT Core | Organization PT Core) Constraints
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| focus | I | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.focus Who/what the section is about, when it is not about the subject of composition DefinitionO foco real da secção quando esta não é o mesmo assunto da composição 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:sectionImmunizations.text Text summary of the section, for human interpretation DefinitionUma narrativa que contém o conteúdo da secção Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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| mode | 0..0 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.mode working | snapshot | changes DefinitionComo a lista foi preparada 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.
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| orderedBy | 0..0 | CodeableConcept PT CoreBinding | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.orderedBy Concept - reference to a terminology or just text DefinitionEspecifica a ordem aplicada aos itens nas entradas da secção. Usar o system http://terminology.hl7.org/CodeSystem/list-order Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. What order applies to the items in the entry.
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| entry | I | 0..* | Reference(List PT PS) | Element idComposition.section:sectionImmunizations.entry A reference to data that supports this section DefinitionReferência aos recursos que suportam esta secção If there are no entries in the list, an emptyReason SHOULD be provided.
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| emptyReason | I | 0..0 | CodeableConcept PT CoreBinding | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.emptyReason Concept - reference to a terminology or just text DefinitionIndica o motivo pelo qual a secção está vazia Usar o system ttp://terminology.hl7.org/CodeSystem/list-empty-reason Allows capturing things like "none exist" or "not asked" which can be important for most lists. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. If a section is empty, why it is empty.
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| section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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Binding
| Path | Strength | ValueSet | Comment |
|---|---|---|---|
Composition.type | required | https://www.ctc.min-saude.pt/catalogos/apoio-ao-registo-clinico | Value Set Name: DocumentType |
Composition.section.code | required | https://www.ctc.min-saude.pt/catalogos/apoio-ao-registo-clinico | Value Set Name: PatientSummarySection |
Identifier.type | extensible | https://spms.min-saude.pt/iop/valueset/ExtensionIdentifierType | Value Set: ExtensionIdentifierType |
system consultar Systems.
Binding do FHIR Required
| Path | strength | ValueSet |
|---|---|---|
Composition.status |
required |
CompositionStatus |
Composition.confidentiality |
required |
http://terminology.hl7.org/ValueSet/v3-Confidentiality|2.0.0 |
Composition.relatesTo.code |
required |
http://hl7.org/fhir/ValueSet/document-relationship-type|4.3.0 |
Identifiers Type
Estes Identificadores devem ser utilizados no elemento
identifier.type.coding[*]
Regras de implementação
Para além das constraints identificadas pelo FHIR para este recurso devem ser consideradas as constraints que identificamos na tabela infra.