Releases of the PS-CA Implementation Guide may be found on a table on the Home Page of this Project.
Composition (PS-CA)
Additional information on this profile (including the JSON & XML structure and detailed element descriptions) can be found at package/structuredefinition-profile-composition-ca-ps.json
Profile
Composition | I | Composition | Element idComposition Canadian Patient Summary composition DefinitionCanadian Patient Summary composition. A composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained. While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
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id | Σ | 0..1 | string | 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 | 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). A human language.
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text | S | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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contained | 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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versionNumber | I | 0..1 | Extension(string) | There are no (further) constraints on this element Element idComposition.extension:versionNumber Version-specific identifier for composition Alternate namesextensions, user content DefinitionVersion specific identifier for the composition, assigned when each version is created/updated. While each resource, including the composition itself, has its own version identifier, this is a formal identifier for the logical version of the composition as a whole. It would remain constant if the resources were moved to a new server, and all got new individual resource versions, for example. http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber 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 | S Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idComposition.identifier Version-independent identifier for the Composition DefinitionA version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time. Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.
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status | S Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idComposition.status preliminary | final | amended | entered-in-error DefinitionThe workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. Need to be able to mark interim, amended, or withdrawn compositions or documents. If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. The workflow/clinical status of the composition.
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type | S Σ | 1..1 | CodeableConceptBindingPattern | Element idComposition.type Kind of composition ("Patient Summary") DefinitionSpecifies that this composition refers to a Patient Summary (Loinc "60591-5") Key metadata element describing the composition, used in searching/filtering. For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. Type of a composition.
{ "coding": [ { "system": "http://loinc.org", "code": "60591-5" } ] }
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category | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idComposition.category Categorization of Composition DefinitionA categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type. Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. This is a metadata field from XDS/MHD. High-level kind of a clinical document at a macro level.
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subject | S Σ I | 1..1 | Reference(package/structuredefinition-profile-patient-ca-ps.json) | Element idComposition.subject Who and/or what the composition is about DefinitionWho or what the composition is about. In general a composition can be about a person, (patient or healthcare practitioner), a device (e.g., a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). For the PS the subject is always the patient. Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. For clinical documents, this is usually the patient. Reference(package/structuredefinition-profile-patient-ca-ps.json) Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.subject.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.subject.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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reference | S Σ I | 1..1 | string | There are no (further) constraints on this element Element idComposition.subject.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idComposition.subject.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idComposition.subject.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.subject.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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encounter | Σ I | 0..1 | Reference(Encounter) | Element idComposition.encounter Context of the Composition DefinitionDescribes the clinical encounter or type of care this documentation is associated with. Provides context for the composition and supports searching. While IPS-UV considers this a Must Support element, policy has not yet been developed in Canada confirming the expectations for when a patient summary is created (e.g., does it have to be created by a health professional or just validated, can it be automatically assembled, does it have to occur within an encounter, etc.). This relaxation does not exclude or prevent implementers from further defining how encounter is used in their implementation if their use case(s) rely on its presence.
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date | S Σ | 1..1 | dateTime | There are no (further) constraints on this element Element idComposition.date Composition editing time DefinitionThe composition editing time, when the composition was last logically changed by the author. dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. The Last Modified Date on the composition may be after the date of the document was attested without being changed.
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author | S Σ I | 1..* | Reference(package/structuredefinition-profile-practitioner.json | package/structuredefinition-profile-practitionerrole.json | Device | package/structuredefinition-profile-patient-ca-ps.json | RelatedPerson | package/structuredefinition-profile-organization.json) | Element idComposition.author Who and/or what authored the patient summary DefinitionIdentifies who is responsible for the information in the patient summary, not necessarily who typed it in. The type of author(s) contribute to determine the "nature"of the Patient Summary: e.g., a "human-curated" PS Vs. an "automatically generated" PS. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(package/structuredefinition-profile-practitioner.json | package/structuredefinition-profile-practitionerrole.json | Device | package/structuredefinition-profile-patient-ca-ps.json | RelatedPerson | package/structuredefinition-profile-organization.json) Constraints
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title | S Σ | 1..1 | string | Element idComposition.title CA Patient Summary DefinitionOfficial human-readable label for the composition. For this document should be "CA Patient Summary" or any equivalent translation For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.
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confidentiality | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.confidentiality As defined by affinity domain DefinitionThe code specifying the level of confidentiality of the Composition. The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. Codes specifying the level of confidentiality of the composition.
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attester | 0..* | BackboneElement | Element idComposition.attester Attests to accuracy of composition DefinitionA participant who has attested to the accuracy of the composition/document. Identifies responsibility for the accuracy of the composition content. IPS-UV flags this as a Must Support element. It is not currently flagged as Must Support in PS-CA, as stakeholders have indicated the element may not be supported across workflows of Canadian jurisdictional implementers. These challenges have been raised in IPS. Further assessment of jurisdictional use cases need to be explored by the Patient Summary Working Group before the constraint will be re-considered for inclusion
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.attester.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.attester.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.attester.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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mode | S | 1..1 | codeBinding | Element idComposition.attester.mode personal | professional | legal | official DefinitionThe type of attestation the authenticator offers. Indicates the level of authority of the attestation. While Composition.attester is not currently flagged as Must Support in PS-CA, Implementers who support attester are expected to support attester.mode, attester.time, and attester.party The way in which a person authenticated a composition.
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time | S | 0..1 | dateTime | Element idComposition.attester.time When the composition was attested DefinitionWhen the composition was attested by the party. Identifies when the information in the composition was deemed accurate. (Things may have changed since then.). While Composition.attester is not currently flagged as Must Support in PS-CA, Implementers who support attester are expected to support attester.mode, attester.time, and attester.party
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party | S I | 0..1 | Reference(package/structuredefinition-profile-patient-ca-ps.json | RelatedPerson | package/structuredefinition-profile-practitioner.json | package/structuredefinition-profile-practitionerrole.json | package/structuredefinition-profile-organization.json) | Element idComposition.attester.party Who attested the composition DefinitionWho attested the composition in the specified way. Identifies who has taken on the responsibility for accuracy of the composition content. While Composition.attester is not currently flagged as Must Support in PS-CA, Implementers who support attester are expected to support attester.mode, attester.time, and attester.party Reference(package/structuredefinition-profile-patient-ca-ps.json | RelatedPerson | package/structuredefinition-profile-practitioner.json | package/structuredefinition-profile-practitionerrole.json | package/structuredefinition-profile-organization.json) Constraints
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custodian | S Σ I | 0..1 | Reference(package/structuredefinition-profile-organization.json) | Element idComposition.custodian Organization which maintains the composition DefinitionIdentifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. Identifies where to go to find the current version, where to report issues, etc. This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged. Reference(package/structuredefinition-profile-organization.json) Constraints
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relatesTo | 0..* | BackboneElement | There are no (further) constraints on this element Element idComposition.relatesTo Relationships to other compositions/documents DefinitionRelationships that this composition has with other compositions or documents that already exist. A document is a version specific composition.
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id | 0..1 | string | 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 DefinitionThe type of relationship that this composition has with anther composition or document. If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. The type of relationship between documents.
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target[x] | 1..1 | There are no (further) constraints on this element Element idComposition.relatesTo.target[x] Target of the relationship DefinitionThe target composition/document of this relationship.
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targetIdentifier | Identifier | Data type | ||
targetReference | Reference(Composition | package/structuredefinition-profile-composition-ca-ps.json) | Data type Reference(Composition | package/structuredefinition-profile-composition-ca-ps.json) | ||
event | Σ | 0..* | BackboneElement | Element idComposition.event The clinical service(s) being documented DefinitionIPS Note: The main activity being described by a PS is the provision of healthcare over a period of time. In the CDA representation of the PS this is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. In the FHIR representation at least one event should be used to record this information. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). For example if the PS is generated by a GP based on information recorded in his/her EHR-S, then the start value should represent the date when the treatment relationship between the patient and the GP started; and the end value the date of the latest care event. Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. The event needs to be consistent with the type element, though can provide further information if desired. Unordered, Open, by code(Pattern) Constraints
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(All Slices) | There are no (further) constraints on this element | |||
id | 0..1 | string | 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 | There are no (further) constraints on this element Element idComposition.event.code Code(s) that apply to the event being documented DefinitionThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries. This list of codes represents the main clinical acts being documented.
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idComposition.event.period The period covered by the documentation DefinitionThe period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idComposition.event.detail The event(s) being documented DefinitionThe description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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careProvisioningEvent | Σ | 0..1 | BackboneElement | Element idComposition.event:careProvisioningEvent The care provisioning being documented DefinitionThe provision of healthcare over a period of time this PS is documented. Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. The event needs to be consistent with the type element, though can provide further information if desired.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.event:careProvisioningEvent.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:careProvisioningEvent.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:careProvisioningEvent.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 | S Σ | 1..* | CodeableConceptPattern | Element idComposition.event:careProvisioningEvent.code Code(s) that apply to the event being documented DefinitionThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. While Composition.event:careProvisioningEvent slice is not currently flagged as Must Support in PS-CA, Implementers who support the slice are expected to support Composition.event:careProvisioningEvent.code and Composition.event:careProvisioningEvent.period This list of codes represents the main clinical acts being documented.
{ "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ActClass", "code": "PCPR" } ] }
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period | S Σ I | 0..1 | Period | Element idComposition.event:careProvisioningEvent.period The period covered by the documentation DefinitionThe period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. While Composition.event:careProvisioningEvent slice is not currently flagged as Must Support in PS-CA, Implementers who support the slice are expected to support Composition.event:careProvisioningEvent.code and Composition.event:careProvisioningEvent.period
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detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idComposition.event:careProvisioningEvent.detail The event(s) being documented DefinitionThe description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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section | S I | 1..* | BackboneElement | Element idComposition.section Sections composing the PS DefinitionThe root of the sections that make up the PS-CA composition. Unordered, Open, by code(Pattern) Constraints
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(All Slices) | There are no (further) constraints on this element | |||
id | 0..1 | string | 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 DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | package/structuredefinition-profile-codeableconcept-ca-ps.json | Element idComposition.section.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. For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text. package/structuredefinition-profile-codeableconcept-ca-ps.json BindingClassification of a section of a composition/document.
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element idComposition.section.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section.entry A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..* | see (section) | There are no (further) constraints on this element Element idComposition.section.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionMedications | S I | 1..1 | BackboneElement | Element idComposition.section:sectionMedications PS-CA Medication Summary Section DefinitionThe medication summary section contains a description of the patient's medications relevant for the scope of the patient summary. The actual content could depend on the jurisdiction, it could report:
Because This section has been expanded in the PS-CA to model a medicationRequest profile in addition to medicationStatement profile initially included in IPS-UV. IPS-UV requires a minimum cardinality of 1 on this section to ensure it is always populated with some kind of data - though has recently updated to allow for the provision of section.emptyReason. This constraint has been maintained in the PS-CA. Systems should utilize the section.entry with a resource when conveying that the subject has no known medications (e.g., clinical assertions that are captured alongside supportive data like date). The section.emptyReason is available to convey details for why the section entry is empty (e.g., data unavailable).
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionMedications.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:sectionMedications.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:sectionMedications.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 | S | 1..1 | string | Element idComposition.section:sectionMedications.title Medication Summary section Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Medication Summary Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionMedications.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "10160-0" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionMedications.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionMedications.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:sectionMedications.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionMedications.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionMedications.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionMedications.entry Medications relevant for the scope of the patient summary DefinitionThis list the medications relevant for the scope of the patient summary or it is used to indicate that the subject is known not to be on any relevant medication This entry requires a medicationStatement or a medicationRequest. Unordered, Open, by resolve()(Profile) Constraints
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medicationStatement | I | 0..* | Reference(package/structuredefinition-profile-medicationstatement-ca-ps.json) | Element idComposition.section:sectionMedications.entry:medicationStatement A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(package/structuredefinition-profile-medicationstatement-ca-ps.json) Constraints
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medicationRequest | I | 0..* | Reference(package/structuredefinition-profile-medicationrequest-ca-ps.json) | Element idComposition.section:sectionMedications.entry:medicationRequest A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(package/structuredefinition-profile-medicationrequest-ca-ps.json) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionMedications.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionMedications.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionAllergies | S I | 1..1 | BackboneElement | Element idComposition.section:sectionAllergies PS-CA Allergies and Intolerances Section DefinitionThis section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g., rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this should be clearly documented in the section. IPS-UV requires a minimum cardinality of 1 on this section to ensure it is always populated with some kind of data - though has recently updated to allow for the provision of section.emptyReason. This constraint has been maintained in the PS-CA. Systems should utilize the section.entry with a resource when conveying that the subject has no known allergies (e.g., clinical assertions that are captured alongside supportive data like date). The section.emptyReason is available to convey details for why the section entry is empty (e.g., data unavailable).
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id | 0..1 | string | There are no (further) constraints on this element 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.
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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 | S | 1..1 | string | Element idComposition.section:sectionAllergies.title Allergies and Intolerances Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionAllergies.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "48765-2" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | 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 DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionAllergies.entry Relevant allergies or intolerances (conditions) for that patient. DefinitionIt lists the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g., rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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allergyOrIntolerance | I | 0..* | Reference(package/structuredefinition-profile-allergyintolerance-ca-ps.json) | Element idComposition.section:sectionAllergies.entry:allergyOrIntolerance A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(package/structuredefinition-profile-allergyintolerance-ca-ps.json) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionAllergies.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionProblems | S I | 1..1 | BackboneElement | Element idComposition.section:sectionProblems PS-CA Problems Section DefinitionThe PS problem section lists and describes clinical problems or conditions currently being monitored for the patient. IPS-UV requires a minimum cardinality of 1 on this section to ensure it is always populated with some kind of data - though has recently updated to allow for the provision of section.emptyReason. This constraint has been maintained in the PS-CA. Systems should utilize the section.entry with a resource when conveying that the subject has no known conditions (e.g., clinical assertions that are captured alongside supportive data like date). The section.emptyReason is available to convey details for why the section entry is empty (e.g., data unavailable).
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionProblems.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:sectionProblems.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:sectionProblems.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 | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionProblems.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionProblems.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "11450-4" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionProblems.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionProblems.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:sectionProblems.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionProblems.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionProblems.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionProblems.entry Clinical problems or conditions currently being monitored for the patient. DefinitionIt lists and describes clinical problems or conditions currently being monitored for the patient. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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problem | I | 0..* | Reference(package/structuredefinition-profile-condition-ca-ps.json) | Element idComposition.section:sectionProblems.entry:problem A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(package/structuredefinition-profile-condition-ca-ps.json) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionProblems.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionProblems.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionProceduresHx | I | 0..1 | BackboneElement | Element idComposition.section:sectionProceduresHx PS-CA History of Procedures Section DefinitionThe History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to:
IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error. Additionally vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionProceduresHx.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:sectionProceduresHx.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:sectionProceduresHx.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 | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionProceduresHx.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionProceduresHx.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "47519-4" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionProceduresHx.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionProceduresHx.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:sectionProceduresHx.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionProceduresHx.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionProceduresHx.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionProceduresHx.entry Patient past procedures pertinent to the scope of this document. DefinitionIt lists the patient past procedures that are pertinent to the scope of this document. Procedures may refer for example to:
If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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procedure | S I | 0..* | Reference(package/structuredefinition-profile-procedure-ca-ps.json) | Element idComposition.section:sectionProceduresHx.entry:procedure A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(package/structuredefinition-profile-procedure-ca-ps.json) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionProceduresHx.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionProceduresHx.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionImmunizations | I | 0..1 | BackboneElement | Element idComposition.section:sectionImmunizations PS-CA Immunizations Section DefinitionThe Immunizations Section defines a patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. The section includes the current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized. IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error. Additionally vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content
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id | 0..1 | string | There are no (further) constraints on this element 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.
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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 | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionImmunizations.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "11369-6" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | 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 DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionImmunizations.entry Patient's immunization status and pertinent history. DefinitionIt defines the patient's current immunization status and pertinent immunization history. The primary use case for the Immunization Section is to enable communication of a patient's immunization status. It may contain the entire immunization history that is relevant to the period of time being summarized. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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immunization | S I | 0..* | Reference(package/structuredefinition-profile-immunization-ca-ps.json) | Element idComposition.section:sectionImmunizations.entry:immunization A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(package/structuredefinition-profile-immunization-ca-ps.json) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionImmunizations.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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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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sectionMedicalDevices | I | 0..1 | BackboneElement | Element idComposition.section:sectionMedicalDevices PS-CA Medical Devices Section DefinitionThe medical devices section contains narrative text and coded entries describing the patient history of medical device use. IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries, future releases may further constrain this section as more jurisdictions look to support its use
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionMedicalDevices.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:sectionMedicalDevices.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:sectionMedicalDevices.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 | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionMedicalDevices.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionMedicalDevices.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "46264-8" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionMedicalDevices.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionMedicalDevices.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:sectionMedicalDevices.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionMedicalDevices.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionMedicalDevices.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionMedicalDevices.entry Patient history of medical device use. DefinitionIt describes the patient history of medical device use. This entry shall be used to document that no information about medical device use is available, or that no relevant medical device use is known. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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deviceStatement | S I | 0..* | Reference(Device Use Statement (IPS)) | Element idComposition.section:sectionMedicalDevices.entry:deviceStatement A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. Pending definition of a PS CA device use section profile in a future release of PS CA, implementors are encouraged to use the IPS device use section profile. Reference(Device Use Statement (IPS)) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionMedicalDevices.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionMedicalDevices.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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sectionResults | I | 0..1 | BackboneElement | Element idComposition.section:sectionResults PS-CA Results Section DefinitionThis section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results. IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error. Additionally vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionResults.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:sectionResults.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:sectionResults.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 | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionResults.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionResults.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "30954-2" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionResults.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionResults.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:sectionResults.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionResults.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionResults.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionResults.entry Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. DefinitionRelevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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results-observation | S I | 0..* | Reference(package/structuredefinition-profile-observation-results-ca-ps.json) | Element idComposition.section:sectionResults.entry:results-observation A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. Further specializations of the observation profiles are available in this guide, however the parent result profile has been provided below to simplify validation. Reference(package/structuredefinition-profile-observation-results-ca-ps.json) Constraints
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results-diagnosticReport | S I | 0..* | Reference(package/structuredefinition-profile-diagnosticreport-ca-ps.json) | Element idComposition.section:sectionResults.entry:results-diagnosticReport A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. Pending definition of a PS CA diagnostic report profile in a future release of PS CA, implementors are encouraged to use the IPS diagnostic report profile. Reference(package/structuredefinition-profile-diagnosticreport-ca-ps.json) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionResults.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionResults.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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sectionVitalSigns | I | 0..1 | BackboneElement | Element idComposition.section:sectionVitalSigns PS-CA Vital Signs Section DefinitionThe Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error. Additionally vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionVitalSigns.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:sectionVitalSigns.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:sectionVitalSigns.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 | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionVitalSigns.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionVitalSigns.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "8716-3" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionVitalSigns.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionVitalSigns.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:sectionVitalSigns.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionVitalSigns.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionVitalSigns.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionVitalSigns.entry Notable vital signs or physical findings. DefinitionNotable vital signs or physical findings as: blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included IPS-UV and PS-CA point to the parent vital signs profile (http://hl7.org/fhir/StructureDefinition/vitalsigns) in the base FHIR specification, it is up to the jurisdictions to select and support the individual vital sign profiles. However, to support implementers in validation - the individual vital signs profiles have been included as individual slices below. The parent vital signs profile has been removed as a slice to prevent examples from matching multiple slices. Unordered, Open, by resolve()(Profile) Constraints
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BMI | I | 0..* | Reference(Observation Body Mass Index Profile) | Element idComposition.section:sectionVitalSigns.entry:BMI A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Observation Body Mass Index Profile) Constraints
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BP | I | 0..* | Reference(Observation Blood Pressure Profile) | Element idComposition.section:sectionVitalSigns.entry:BP A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Observation Blood Pressure Profile) Constraints
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BodyHeight | I | 0..* | Reference(Observation Body Height Profile) | Element idComposition.section:sectionVitalSigns.entry:BodyHeight A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Observation Body Height Profile) Constraints
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BodyTemp | I | 0..* | Reference(Observation Body Temperature Profile) | Element idComposition.section:sectionVitalSigns.entry:BodyTemp A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Observation Body Temperature Profile) Constraints
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BodyWeight | I | 0..* | Reference(Observation Body Weight Profile) | Element idComposition.section:sectionVitalSigns.entry:BodyWeight A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Observation Body Weight Profile) Constraints
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HeadCircum | I | 0..* | Reference(Observation Head Circumference Profile) | Element idComposition.section:sectionVitalSigns.entry:HeadCircum A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Observation Head Circumference Profile) Constraints
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HeartRate | I | 0..* | Reference(Observation Heart Rate Profile) | Element idComposition.section:sectionVitalSigns.entry:HeartRate A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Observation Heart Rate Profile) Constraints
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OxygenSat | I | 0..* | Reference(Observation Oxygen Saturation Profile) | Element idComposition.section:sectionVitalSigns.entry:OxygenSat A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Observation Oxygen Saturation Profile) Constraints
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RespRate | I | 0..* | Reference(Observation Respiratory Rate Profile) | Element idComposition.section:sectionVitalSigns.entry:RespRate A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Observation Respiratory Rate Profile) Constraints
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VitalsPanel | I | 0..* | Reference(Observation Vital Signs Panel Profile) | Element idComposition.section:sectionVitalSigns.entry:VitalsPanel A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(Observation Vital Signs Panel Profile) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionVitalSigns.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionVitalSigns.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionPastIllnessHx | I | 0..1 | BackboneElement | Element idComposition.section:sectionPastIllnessHx PS-CA History of Past Illness Section DefinitionThe History of Past Illness section contains a description of the conditions the patient suffered in the past. IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error. Additionally vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionPastIllnessHx.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:sectionPastIllnessHx.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:sectionPastIllnessHx.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 | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionPastIllnessHx.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionPastIllnessHx.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "11348-0" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionPastIllnessHx.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionPastIllnessHx.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:sectionPastIllnessHx.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionPastIllnessHx.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionPastIllnessHx.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionPastIllnessHx.entry Conditions the patient suffered in the past. DefinitionIt contains a description of the conditions the patient suffered in the past. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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pastProblem | S I | 0..* | Reference(package/structuredefinition-profile-condition-ca-ps.json) | Element idComposition.section:sectionPastIllnessHx.entry:pastProblem A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(package/structuredefinition-profile-condition-ca-ps.json) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionPastIllnessHx.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionPastIllnessHx.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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sectionFunctionalStatus | I | 0..1 | BackboneElement | Element idComposition.section:sectionFunctionalStatus PS-CA Functional Status DefinitionThe functional status section shall contain a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments. Profiles to express disabilities and functional assessments will be specified by future versions of this guide. IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionFunctionalStatus.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:sectionFunctionalStatus.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:sectionFunctionalStatus.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 | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionFunctionalStatus.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionFunctionalStatus.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "47420-5" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionFunctionalStatus.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionFunctionalStatus.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:sectionFunctionalStatus.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionFunctionalStatus.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionFunctionalStatus.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionFunctionalStatus.entry Optional entry used to represent disabilities and functional assessments DefinitionIt describes capabilities of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments. Profiles to express disabilities and functional assessments will be specified by future versions of this guide. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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disability | S I | 0..* | Reference(package/structuredefinition-profile-condition-ca-ps.json) | Element idComposition.section:sectionFunctionalStatus.entry:disability A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(package/structuredefinition-profile-condition-ca-ps.json) Constraints
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functionalAssessment | S I | 0..* | Reference(ClinicalImpression) | Element idComposition.section:sectionFunctionalStatus.entry:functionalAssessment A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionFunctionalStatus.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionFunctionalStatus.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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sectionPlanOfCare | I | 0..1 | BackboneElement | Element idComposition.section:sectionPlanOfCare PS-CA Plan of Care Section DefinitionThe plan of care section contains a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionPlanOfCare.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:sectionPlanOfCare.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:sectionPlanOfCare.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 | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionPlanOfCare.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionPlanOfCare.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "18776-5" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionPlanOfCare.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionPlanOfCare.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:sectionPlanOfCare.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionPlanOfCare.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionPlanOfCare.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | I | 0..* | Reference(Resource) | Element idComposition.section:sectionPlanOfCare.entry Optional entry used to represent structured care plans DefinitionDynamic, personalized plan including identified needed healthcare activity, health objectives and healthcare goals, relating to one or more specified health issues in a healthcare process [Source EN ISO 13940] If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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carePlan | I | 0..* | Reference(CarePlan) | Element idComposition.section:sectionPlanOfCare.entry:carePlan A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionPlanOfCare.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionPlanOfCare.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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sectionSocialHistory | I | 0..1 | BackboneElement | Element idComposition.section:sectionSocialHistory PS-CA Social History Section DefinitionThe social history section contains a description of the person’s Health related "lifestyle factors" or "lifestyle observations" (e.g., smoke habits; alcohol consumption; diets, risky habits.) IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error. Additionally vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionSocialHistory.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:sectionSocialHistory.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:sectionSocialHistory.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 | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionSocialHistory.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionSocialHistory.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "29762-2" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionSocialHistory.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionSocialHistory.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:sectionSocialHistory.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionSocialHistory.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionSocialHistory.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionSocialHistory.entry Health related "lifestyle factors" or "lifestyle observations" (e.g., smoke habits; alcohol consumption; diets, risky habits.) DefinitionDescription of the person’s Health related “lifestyle factors" or "lifestyle observations" (e.g., smoke habits; alcohol consumption; diets, risky habits.) If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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generalSocialHistory | I | 0..* | Reference(package/structuredefinition-profile-observation-socialhistory-ca-ps.json) | Element idComposition.section:sectionSocialHistory.entry:generalSocialHistory A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(package/structuredefinition-profile-observation-socialhistory-ca-ps.json) Constraints
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smokingTobaccoUse | I | 0..1 | Reference(package/structuredefinition-profile-observation-tobaccouse-ca-ps.json) | Element idComposition.section:sectionSocialHistory.entry:smokingTobaccoUse A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(package/structuredefinition-profile-observation-tobaccouse-ca-ps.json) Constraints
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alcoholUse | I | 0..1 | Reference(package/structuredefinition-profile-observation-alcoholuse-ca-ps.json) | Element idComposition.section:sectionSocialHistory.entry:alcoholUse A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(package/structuredefinition-profile-observation-alcoholuse-ca-ps.json) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionSocialHistory.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionSocialHistory.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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sectionPregnancyHx | I | 0..1 | BackboneElement | Element idComposition.section:sectionPregnancyHx PS-CA History of Pregnancy Section DefinitionThe history of pregnancy section shall contain information about whether the patient is currently pregnant or not. It may contain addition summarizing information about the outcome of earlier pregnancies. IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionPregnancyHx.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:sectionPregnancyHx.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:sectionPregnancyHx.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 | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionPregnancyHx.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionPregnancyHx.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "10162-6" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionPregnancyHx.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionPregnancyHx.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:sectionPregnancyHx.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionPregnancyHx.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionPregnancyHx.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionPregnancyHx.entry Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. DefinitionIt contains information about whether the patient is currently pregnant or not. It may contain addition summarizing information about the outcome of earlier pregnancies. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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pregnancyStatus | S I | 0..* | Reference(Observation - Pregnancy: status) | Element idComposition.section:sectionPregnancyHx.entry:pregnancyStatus A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. Pending definition of a PS CA pregnancy status observation profile in a future release of PS CA, implementors are encouraged to use the IPS pregnancy status observation profile. Reference(Observation - Pregnancy: status) Constraints
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pregnancyOutcomeSummary | S I | 0..* | Reference(Observation - Pregnancy: outcome) | Element idComposition.section:sectionPregnancyHx.entry:pregnancyOutcomeSummary A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. Pending definition of a PS CA pregnancy outcome observation profile in a future release of PS CA, implementors are encouraged to use the IPS pregnancy outcome observation profile. Reference(Observation - Pregnancy: outcome) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionPregnancyHx.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionPregnancyHx.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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sectionAdvanceDirectives | I | 0..1 | BackboneElement | Element idComposition.section:sectionAdvanceDirectives PS-CA Advance Directives Section DefinitionThe advance directives section contains a narrative description of patient's advance directive. IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionAdvanceDirectives.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:sectionAdvanceDirectives.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:sectionAdvanceDirectives.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 | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionAdvanceDirectives.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionAdvanceDirectives.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "42348-3" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionAdvanceDirectives.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionAdvanceDirectives.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:sectionAdvanceDirectives.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionAdvanceDirectives.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionAdvanceDirectives.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionAdvanceDirectives.entry Narrative description of the patient's advance directive. DefinitionContains a narrative description or a Consent entry with information about the patient's advance directive. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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advanceDirectivesConsent | S I | 0..* | Reference(Consent) | Element idComposition.section:sectionAdvanceDirectives.entry:advanceDirectivesConsent A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionAdvanceDirectives.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionAdvanceDirectives.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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sectionFamilyHistory | I | 0..1 | BackboneElement | Element idComposition.section:sectionFamilyHistory PS-CA Family History Section DefinitionThe family history section contains a description of the patient's family history. This is a new section being introduced by the PS-CA specification at the request of jurisdictions.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionFamilyHistory.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:sectionFamilyHistory.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:sectionFamilyHistory.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 | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:sectionFamilyHistory.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | S | 1..1 | CodeableConceptPattern | Element idComposition.section:sectionFamilyHistory.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
{ "coding": [ { "system": "http://loinc.org", "code": "10157-6" } ] }
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:sectionFamilyHistory.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:sectionFamilyHistory.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:sectionFamilyHistory.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:sectionFamilyHistory.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionFamilyHistory.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | S I | 0..* | Reference(Resource) | Element idComposition.section:sectionFamilyHistory.entry Narrative description of the patient's family history. DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Unordered, Open, by resolve()(Profile) Constraints
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FamilyMemberHistory | S I | 0..* | Reference(package/structuredefinition-profile-familymemberhistory-ca-ps.json) | Element idComposition.section:sectionFamilyHistory.entry:FamilyMemberHistory A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided. Reference(package/structuredefinition-profile-familymemberhistory-ca-ps.json) Constraints
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:sectionFamilyHistory.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | I | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:sectionFamilyHistory.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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Note: Previously, IPS-UV required a minimum cardinality of 1 and a minimum cardinality of 1 on section.entry for Medications, Allergies, and Problem sections. This prior constraint was intended to ensure these sections are always populated with some kind of entry (FHIR Resource). Through advocacy from Canadian implementers to ask for an alternative way to convey the lack of information/resources for a patient at the Composition level, IPS has shifted to a more nuanced approach.
- IPS UV now allows for Composition.section.emptyReason to be populated and using an invariant to require that either Composition.section.emptyReason or Composition.section.entry be populated for the required sections.
Key Differences between the IPS-UV and PS-CA
Composition:
- Across Composition: Removed redundant data type profiling on fixed/patterned codeable concepts, modified references to point to equivalent PS-CA profiles
Composition.event:careProvisioningEvent
: Relaxed Must Support flag on the CareProvisioningEvent slice due to the scope of the PS-CA needing to support summaries that are generated outside a direct care event (e.g., including summaries that are machine-generated/on-demand). This will continue to be advocated for resolution at the IPS levelComposition.attester
- Relaxed Must Support flag on the element. This decision in this release reflects the understanding of the current variability in workflows among Canadian Jurisdictional implementers, some of whom may not have the capability to populate the attester field at all. Further assessment will be completed against requirements and use cases for PS-CA v2.0.Composition.author
,Composition.attester
,Composition.custodian
- Modified references to point towards Canadian Baseline profiles and the Patient (PS-CA) profile since the IPS-UV currently only offers profiles that are scoped to diagnostic result authoring practitioners, organizations, etc.- Further investigation into whether additional elements/PS-CA profiles are needed (beyond the CA Baseline constraints) to support the use of these elements
Note: Additionally, the use of CA Baseline Pratitioner, PractitionerRole, Organization profiles will be superseded by the CA Core profiles (or profiles that impose the CA Core) in furture releases but the current usage of CA Baseline profiles will be maintained until a further stabilized CA Core profile (or further Patient Summary requirements) exist.
Note: Since the previous release of this specification, the modelling in IPS-UV that prohibited the use of section.emptyReason has been removed. See note above.
Composition Sections
Composition.sectionProceduresHx
+ Composition.sectionImmunizations
+ Composition.sectionResults
+ Composition.sectionMedicalDevices
:
Removed Must Support flag from these sections according to principles found in Profiling Conventions and Approach
- IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to not put undue conformance expectations on jurisdictions who will not be including this domain/section in their initial implementation of patient summaries
- Participating jurisdictions are expected to be able to receive this section in a patient summary (e.g., from another jurisdiction) without flagging an error
- Vendors should anticipate that the Must Support flag may be re-evaluated for application in future releases
- Additionally, vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content
Note: Implementers are not expected to demonstrate support for these sections in v1.0.0 TI, but the flags on the child elements have been maintained to ensure that if an implementer does produce these sections, they follow the expected patterning that is outlined in the IPS-UV and future PS-CA releases. See Must Support Definition.
Note: In earlier releases, IPS-UV has removed the Must Support flag on the following sections: Vital signs, PastIllnessHx, FunctionalStatus, PlanOfCare, Social History, PregnancyHx, AdvanceDirectives - bringing PS-CA into futher alignment with IPS-UV
Composition.sectionSocialHistory
+ Composition.sectionFamilyMemberHistory
:
- Added FamilyMemberHistory section to meet the needs of jurisidctions wanting to pilot FamilyMemberHistory profile as part of their patient summary initiative
- Expanded the sectionSocialHistory by including a new profile in addition to the Tobacco Use & Alcohol Use profiles to enable a more generalized social history profile to support implementers piloting a broader set of social history observations (not expected to be housed under the structured alcohol user and tobacco use profiles), and to house coded and non-coded lifestyle risk factors (e.g., amount of exercise, etc.)