Documents

Para cada um dos recursos categorizados como Documents apresenta-se um modelo, correspondente à sistematização dos artefactos de interoperabilidade relevantes no contexto de cada um dos recursos definidos no capítulo Profiles, assim como a estrutura do respetivo recurso. Em cada modelo de recurso identificam-se os value set relevantes, sistemas de codificação e catálogos associados e recursos referenciados. A amarelo-claro assinalam-se os value sets que não se encontram sob a gestão do Centro de Terminologias Clínicas (CTC), nos quais se incluem os value sets do FHIR com binding required. Os restantes value sets foram trabalhados no contexto do CTC. Os catálogos envolvidos nesta secção encontram-se assinalados a laranja.

Profiles

Profile	Description
Composition profile	O recurso Composition corresponde a um conjunto de informações de saúde do utente que são agrupadas e fornecem informação agregada sobre o utente. O Composition define a estrutura e o conteúdo necessários para um documento, não constituindo este, no entanto, no documento em si.

Composition

Para mais informações sobre a implementação genérica deste recurso consultar: Composition profile

Modelo de Artefactos de Interoperabilidade

Os value sets que se encontram descritos nas figuras anteriores mas não estão publicados no site CTC encontram-se, ainda, em fase de elaboração, motivo pelo qual ainda não se encontram disponíveis.

Estrutura do Recurso

CompositionPTCore (Composition)	I		Composition	There are no (further) constraints on this element Element id Composition Short description A set of resources composed into a single coherent clinical statement with clinical attestation Definition A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). Comments While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical. Data type Composition Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()` dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource `contained.where(((id.exists() and ('#'+id in (%resource.descendants().reference \| %resource.descendants().as(canonical) \| %resource.descendants().as(uri) \| %resource.descendants().as(url)))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(uri) = '#').exists()).not()).trace('unmatched', id).empty()` dom-6: A resource should have narrative for robust management text.`div`.exists() dom-5: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` Mappings rim: Entity. Role, or Act workflow: Event rim: Document[classCode="DOC" and moodCode="EVN" and isNormalAct()] cda: ClinicalDocument fhirdocumentreference: when described by DocumentReference w5: infrastructure.documents
id	Σ	1..1	id	There are no (further) constraints on this element Element id Composition.id Short description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Data type id
meta	Σ	0..1	MetaPTCore	Element id Composition.meta Short description Metadata about the resource Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. Data type MetaPTCore Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: N/A
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id Composition.implicitRules Short description A set of rules under which this content was created Definition A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Comments Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. Data type uri Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a
language		0..1	codeBinding	There are no (further) constraints on this element Element id Composition.language Short description Language of the resource content Definition The base language in which the resource is written. Comments Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). Data type code Binding IETF language tag CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a
text		0..1	Narrative	There are no (further) constraints on this element Element id Composition.text Short description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Comments Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: N/A rim: Act.text?
contained	I	0..*	Resource	There are no (further) constraints on this element Element id Composition.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. Comments This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. Data type Resource Constraints dom-r4b: Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic) Mappings rim: Entity. Role, or Act rim: N/A
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Composition.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id Composition.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
identifier	Σ	0..1	ExtensionIdentifierPTCore	Element id Composition.identifier Short description An identifier intended for computation Definition Identificador da composição/documento por parte do negócio Comments Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate. Data type ExtensionIdentifierPTCore Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CX / EI (occasionally, more often EI maps to a resource id or a URL) rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd: Identifier workflow: Event.identifier w5: FiveWs.identifier rim: Document.id / Document.setId cda: .setId fhirdocumentreference: DocumentReference.masterIdentifier
id		0..1	id	There are no (further) constraints on this element Element id Composition.identifier.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type id Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Composition.identifier.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
use	Σ ?!	0..1	codeBinding	There are no (further) constraints on this element Element id Composition.identifier.use Short description usual \| official \| temp \| secondary \| old (If known) Definition Propósito do identificador: official: O identificador considerado mais fiável para a identificação do item. temp: Um identificador temporário. secondary: Um identificador que foi atribuído para identificar o item em um contexto relativo, mas não pode usado em um contexto diferente. old: O identificador já não é considerado válido, mas pode ser relevante para fins de pesquisa. Requirements Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Comments Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Data type code Binding IdentifierUse (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: N/A rim: Role.code or implied by context
type	Σ	0..1	CodeableConceptPTCoreBinding	There are no (further) constraints on this element Element id Composition.identifier.type Short description Concept - reference to a terminology or just text Definition A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. Requirements Allows users to make use of identifiers when the identifier system is not known. Comments Value Set: ExtensionIdentifierType Data type CodeableConceptPTCore Binding ExtensionIdentifierType (extensible) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD v2: CX.5 rim: Role.code or implied by context
id		0..1	id	There are no (further) constraints on this element Element id Composition.identifier.type.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type id Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Composition.identifier.type.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
coding	Σ	0..*	CodingPTCore	There are no (further) constraints on this element Element id Composition.identifier.type.coding Short description A reference to a code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Data type CodingPTCore Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
id		0..1	id	Element id Composition.identifier.type.coding.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Comments . Data type id Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Composition.identifier.type.coding.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
system	Σ	1..1	uri	There are no (further) constraints on this element Element id Composition.identifier.type.coding.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously. Data type uri Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE.3 rim:* ./codeSystem orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..0	string	There are no (further) constraints on this element Element id Composition.identifier.type.coding.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data type string Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	1..1	code	There are no (further) constraints on this element Element id Composition.identifier.type.coding.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE.1 rim:* ./code orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	1..1	string	There are no (further) constraints on this element Element id Composition.identifier.type.coding.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE.2 - but note this is not well followed rim:* CV.displayName orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..0	boolean	There are no (further) constraints on this element Element id Composition.identifier.type.coding.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: Sometimes implied by being first rim: CD.codingRationale orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	1..1	string	There are no (further) constraints on this element Element id Composition.identifier.type.text Short description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. Requirements The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Comments Very often the text is the same as a displayName of one of the codings. Data type string Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE.9. But note many systems use CE.2 for this rim: ./originalText[mediaType/code="text/plain"]/data orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
system	Σ	0..1	uri	There are no (further) constraints on this element Element id Composition.identifier.system Short description The namespace for the identifier value Definition Establishes the namespace for the value - that is, a URL that describes a set values that are unique. Requirements There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Comments Para sistemas geridos pela SPMS o system tem de seguir a seguinte estrutura: http://spms.min-saude.pt/<sistema>/identifiers/<identifier-id> Data type uri Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Examples General http://www.acme.com/identifiers/patient Mappings rim: n/a v2: CX.4 / EI-2-4 rim: II.root or Role.id.root servd: ./IdentifierType
value	Σ	1..1	string	There are no (further) constraints on this element Element id Composition.identifier.value Short description The value that is unique Definition The portion of the identifier typically relevant to the user and which is unique within the context of the system. Comments If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. Data type string Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Examples General 123456 Mappings rim: n/a v2: CX.1 / EI.1 rim: II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root) servd: ./Value
period	Σ I	0..1	PeriodPTCore	There are no (further) constraints on this element Element id Composition.identifier.period Short description Time range defined by start and end date/time Alternate names Period Definition A time period defined by a start and end date and optionally time. Comments A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration. Data type PeriodPTCore Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` per-1: If present, start SHALL have a lower value than end `start.hasValue().not() or end.hasValue().not() or (start <= end)` Mappings rim: n/a v2: DR rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"] v2: CX.7 + CX.8 rim: Role.effectiveTime or implied by context servd: ./StartDate and ./EndDate
assigner	Σ I	0..0	Reference(OrganizationPTCore)	There are no (further) constraints on this element Element id Composition.identifier.assigner Short description Organization that issued id (may be just text) Definition Organization that issued/manages the identifier. Comments The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. Data type Reference(OrganizationPTCore) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) v2: CX.4 / (CX.4,CX.9,CX.10) rim: II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper servd: ./IdentifierIssuingAuthority
status	Σ ?!	1..1	codeBinding	Element id Composition.status Short description preliminary \| final \| amended \| entered-in-error Definition Identifica o status da composição/documento Requirements Need to be able to mark interim, amended, or withdrawn compositions or documents. Comments If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. Data type code Binding The workflow/clinical status of the composition. CompositionStatus (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a workflow: Event.status w5: FiveWs.status rim: interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete" cda: n/a fhirdocumentreference: DocumentReference.status
type	Σ	1..1	CodeableConceptPTCoreBinding	Element id Composition.type Short description Concept - reference to a terminology or just text Definition Tipo de composição/documento Requirements Key metadata element describing the composition, used in searching/filtering. Comments Value Set Name: Document Type Data type CodeableConceptPTCore Binding Type of a composition. https://www.ctc.min-saude.pt/catalogos/apoio-ao-registo-clinico (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.code w5: FiveWs.class rim: ./code cda: .code fhirdocumentreference: DocumentReference.type
category	Σ	0..*	CodeableConceptPTCore	Element id Composition.category Short description Concept - reference to a terminology or just text Definition Categoria 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/ Requirements Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. Comments 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. Data type CodeableConceptPTCore Binding High-level kind of a clinical document at a macro level. LoincDocumentOntologyInternational (example) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.subject w5: FiveWs.class rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code cda: n/a fhirdocumentreference: DocumenttReference.category
subject	Σ I	0..1	ReferencePTCore(Resource)	Element id Composition.subject Short description A reference from one resource to another Definition Sobre quem ou o que é a composição ou documento Requirements Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type ReferencePTCore(Resource) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5: FiveWs.subject[x] rim: .participation[typeCode="SBJ"].role[typeCode="PAT"] cda: .recordTarget fhirdocumentreference: DocumentReference.subject w5: FiveWs.subject
encounter	Σ I	0..1	ReferencePTCore(https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/EncounterPTCore)	Element id Composition.encounter Short description A reference from one resource to another Definition Episódio Requirements Provides context for the composition and supports searching. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type ReferencePTCore(https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/EncounterPTCore) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.context w5: FiveWs.context rim: unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct]) cda: .componentOf.encompassingEncounter fhirdocumentreference: DocumentReference.context.encounter
date	Σ	1..1	dateTime	Element id Composition.date Short description Composition editing time Definition Data da composição/documento O período adota o formato definido pela ISO8601 Requirements dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. Comments The Last Modified Date on the composition may be after the date of the document was attested without being changed. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a workflow: Event.occurrence[x] w5: FiveWs.done[x] rim: .effectiveTime[type="TS"] cda: .effectiveTime fhirdocumentreference: DocumentReference.content.attachment.date, DocumentReference.created
author	Σ I	1..*	ReferencePTCore(PractitionerPTCore \| PractitionerRolePTCore \| https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/DevicePTCore \| PatientPTCore \| https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/RelatedPersonPTCore \| OrganizationPTCore)	Element id Composition.author Short description A reference from one resource to another Definition Responsável pela criação do documento Requirements Identifies who is responsible for the content. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type ReferencePTCore(PractitionerPTCore \| PractitionerRolePTCore \| https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/DevicePTCore \| PatientPTCore \| https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/RelatedPersonPTCore \| OrganizationPTCore) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.performer w5: FiveWs.author rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"] cda: .author.assignedAuthor fhirdocumentreference: DocumentReference.agent
title	Σ	1..1	string	Element id Composition.title Short description Human Readable name/title Definition Título do documento Comments For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period. Data type string Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: ./title cda: .title fhirdocumentreference: DocumentReference.description, DocumentReference.content.attachment.title
confidentiality	Σ	0..1	codeBinding	Element id Composition.confidentiality Short description As defined by affinity domain Definition Nível de confidencialidade do documento Comments The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. Data type code Binding Codes specifying the level of confidentiality of the composition. Confidentiality (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: .confidentialityCode cda: .confidentialityCode fhirdocumentreference: DocumentReference.securityLabel
attester		0..*	BackboneElement	Element id Composition.attester Short description Attests to accuracy of composition Definition Identifica a responsabilidade pela precisão do conteúdo da composição/documento. Requirements Identifies responsibility for the accuracy of the composition content. Comments Only list each attester once. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"] cda: .authenticator/.legalAuthenticator fhirdocumentreference: DocumentReference.authenticator
id		0..1	id	There are no (further) constraints on this element Element id Composition.attester.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type id Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Composition.attester.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Composition.attester.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
mode		1..1	codeBinding	There are no (further) constraints on this element Element id Composition.attester.mode Short description personal \| professional \| legal \| official Definition The type of attestation the authenticator offers. Requirements Indicates the level of authority of the attestation. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Binding The way in which a person authenticated a composition. CompositionAttestationMode (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: unique(./modeCode) cda: implied by .authenticator/.legalAuthenticator
time		0..1	dateTime	Element id Composition.attester.time Short description When the composition was attested Definition Data A data adota o formato definido pela ISO8601 Requirements Identifies when the information in the composition was deemed accurate. (Things may have changed since then.). Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: ./time[type="TS" and isNormalDatatype()] cda: .authenticator.time
party	I	0..1	ReferencePTCore(PatientPTCore \| https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/RelatedPersonPTCore \| PractitionerPTCore \| PractitionerRolePTCore \| OrganizationPTCore)	Element id Composition.attester.party Short description A reference from one resource to another Definition Pessoa ou entidade que autenticou a composição/documento Requirements Identifies who has taken on the responsibility for accuracy of the composition content. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type ReferencePTCore(PatientPTCore \| https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/RelatedPersonPTCore \| PractitionerPTCore \| PractitionerRolePTCore \| OrganizationPTCore) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5: FiveWs.witness rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()] cda: .authenticator.assignedEnttty
custodian	Σ I	0..1	ReferencePTCore(OrganizationPTCore)	Element id Composition.custodian Short description A reference from one resource to another Definition Entidade responsável pela composição/documento Requirements Identifies where to go to find the current version, where to report issues, etc. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type ReferencePTCore(OrganizationPTCore) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"] cda: .custodian.assignedCustodian fhirdocumentreference: DocumentReference.custodian
relatesTo		0..*	BackboneElement	There are no (further) constraints on this element Element id Composition.relatesTo Short description Relationships to other compositions/documents Definition Relationships that this composition has with other compositions or documents that already exist. Comments A document is a version specific composition. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: .outboundRelationship cda: .relatedDocument fhirdocumentreference: DocumentReference.relatesTo
id		0..1	id	There are no (further) constraints on this element Element id Composition.relatesTo.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type id Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Composition.relatesTo.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Composition.relatesTo.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
code		1..1	codeBinding	Element id Composition.relatesTo.code Short description replaces \| transforms \| signs \| appends Definition Indica o tipo de relação que esta composição tem com outra composição ou documento Comments If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. Data type code Binding The type of relationship between documents. DocumentRelationshipType (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: .outboundRelationship.typeCode cda: .relatedDocument.typeCode fhirdocumentreference: DocumentReference.relatesTo.code
target[x]		1..1		Element id Composition.relatesTo.target[x] Short description Target of the relationship Definition Composição/documento de destino desse relacionamento. Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: .target[classCode="DOC", moodCode="EVN"].id cda: .relatedDocument.id fhirdocumentreference: DocumentReference.relatesTo.target
targetIdentifier			IdentifierPTCore	Data type IdentifierPTCore
targetReference			ReferencePTCore(CompositionPTCore)	Data type ReferencePTCore(CompositionPTCore)
event	Σ	0..*	BackboneElement	Element id Composition.event Short description The clinical service(s) being documented Definition Indica o serviço documentado Requirements Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. Comments The event needs to be consistent with the type element, though can provide further information if desired. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT'] cda: .documentationOf.serviceEvent fhirdocumentreference: DocumentReference.event
id		0..1	id	There are no (further) constraints on this element Element id Composition.event.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type id Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Composition.event.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Composition.event.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
code	Σ	0..*	CodeableConceptPTCore	Element id Composition.event.code Short description Concept - reference to a terminology or just text Definition Representa os principais atos clínicos. Usar o system http://terminology.hl7.org/CodeSystem/v3-ActCode Comments 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. Data type CodeableConceptPTCore Binding This list of codes represents the main clinical acts being documented. ActCode (example) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD rim: .code cda: .code fhirdocumentreference: DocumentReference.event.code
period	Σ I	0..1	PeriodPTCore	Element id Composition.event.period Short description Time range defined by start and end date/time Alternate names Period Definition Período O período adota o formato definido pela ISO8601 Comments A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration. Data type PeriodPTCore Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` per-1: If present, start SHALL have a lower value than end `start.hasValue().not() or end.hasValue().not() or (start <= end)` Mappings rim: n/a v2: DR rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"] rim: .effectiveTime cda: .effectiveTime fhirdocumentreference: DocumentReference.event.period
detail	Σ I	0..*	ReferencePTCore(Resource)	Element id Composition.event.detail Short description A reference from one resource to another Definition Referência do(s) evento(s) que está(ão) sendo documentado(s). Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type ReferencePTCore(Resource) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim: .outboundRelationship[typeCode="SUBJ"].target cda: n/a
section	I	0..*	BackboneElement	There are no (further) constraints on this element Element id Composition.section Short description Composition is broken into sections Definition The root of the sections that make up the composition. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` cmp-1: A section must contain at least one of text, entries, or sub-sections `text.exists() or entry.exists() or section.exists()` cmp-2: A section can only have an emptyReason if it is empty `emptyReason.empty() or entry.empty()` Mappings rim: n/a rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] cda: .component.structuredBody.component.section
id		0..1	id	There are no (further) constraints on this element Element id Composition.section.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type id Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Composition.section.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Composition.section.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
title		0..1	string	Element id Composition.section.title Short description Label for section (e.g. for ToC) Alternate names header, label, caption Definition Título da secção Requirements Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. Comments The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. Data type string Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: ./title cda: .title
code		0..1	CodeableConcept	Element id Composition.section.code Short description Classification of section (recommended) Definition Identifica o tipo de conteúdo presente na secção Requirements Provides computable standardized labels to topics within the document. Comments The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Data type CodeableConcept Binding Classification of a section of a composition/document. DocumentSectionCodes (example) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD rim: ./code cda: .code
author	I	0..*	ReferencePTCore(PractitionerPTCore \| PractitionerRolePTCore \| https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/DevicePTCore \| PatientPTCore \| https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/RelatedPersonPTCore \| OrganizationPTCore)	Element id Composition.section.author Short description A reference from one resource to another Definition Indica o responsável pelas informações nesta secção, não necessariamente quem as digitou. Requirements Identifies who is responsible for the content. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type ReferencePTCore(PractitionerPTCore \| PractitionerRolePTCore \| https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/DevicePTCore \| PatientPTCore \| https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/RelatedPersonPTCore \| OrganizationPTCore) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5: FiveWs.author rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"] cda: .author.assignedAuthor
focus	I	0..1	ReferencePTCore(Resource)	Element id Composition.section.focus Short description A reference from one resource to another Definition O foco real da secção quando esta não é o mesmo assunto da composição Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type ReferencePTCore(Resource) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) cda: .subject? (CDA did not differentiate between subject and focus)
text	I	0..1	Narrative	Element id Composition.section.text Short description Text summary of the section, for human interpretation Definition Uma narrativa que contém o conteúdo da secção Comments Document profiles may define what content should be represented in the narrative to ensure clinical safety. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a rim: N/A rim: .text cda: .text
mode		0..1	codeBinding	Element id Composition.section.mode Short description working \| snapshot \| changes Definition Como a lista foi preparada Requirements Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. Comments This element is labeled as a modifier because a change list must not be misunderstood as a complete list. Data type code Binding The processing mode that applies to this section. ListMode (required) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a w5: FiveWs.class rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value cda: n/a
orderedBy		0..1	CodeableConceptPTCoreBinding	Element id Composition.section.orderedBy Short description Concept - reference to a terminology or just text Definition Especifica a ordem aplicada aos itens nas entradas da secção. Usar o system http://terminology.hl7.org/CodeSystem/list-order Requirements Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Comments 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. Data type CodeableConceptPTCore Binding What order applies to the items in the entry. ListOrderCodes (preferred) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1 cda: n/a
entry	I	0..*	ReferencePTCore(Resource)	Element id Composition.section.entry Short description A reference from one resource to another Definition Referência aos recursos que suportam esta secção Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type ReferencePTCore(Resource) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] cda: .entry
emptyReason	I	0..1	CodeableConceptPTCoreBinding	Element id Composition.section.emptyReason Short description Concept - reference to a terminology or just text Definition Indica o motivo pelo qual a secção está vazia Usar o system ttp://terminology.hl7.org/CodeSystem/list-empty-reason Requirements Allows capturing things like "none exist" or "not asked" which can be important for most lists. Comments 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. Data type CodeableConceptPTCore Binding If a section is empty, why it is empty. ListEmptyReasons (preferred) Constraints ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource `hasValue() or (children().count() > id.count()) or $this is Parameters` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD] cda: n/a
section	I	0..*	see (section)	There are no (further) constraints on this element Element id Composition.section.section Short description Nested Section Definition A nested sub-section within this section. Comments Nested sections are primarily used to help human readers navigate to particular portions of the document. Mappings rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] cda: .component.section

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