OTNotes
This resource (Operating Theatre Notes) represents clinical documentation created during and after a surgical procedure in the operating theatre (OT). These notes typically include details such as the patient's identity, the surgical procedure performed, indications for surgery, anesthesia used, intraoperative findings, steps of the operation, any complications, and immediate postoperative instructions. The Composition resource will be used to store the various sections of the OT notes.
Business Information Model
Key Design Considerations
Composition.typewill be used to differentiate the various documents as indicated in FHIR Document Type Codes). In this case,type.coding.codeshould store11504-8.Composition.section.codewill be used to differentiate the various section types as indicated in Document Section Code Value Set29554-3for the Procedures section.85847-2for the Practitioners section.29548-5for the Conditions section.8716-3for the Observations section.29549-3for the MedicationAdministrations section.46264-8for the Devices section.34895-3for the DiagnosticReports section.59773-2for the Specimens section.28570-0for the FileAttachments section.
An OT Notes document contains one or more procedures performed on a patient. A sequence number is tag to each procedure to track the sequential order in which each procedure is performed.
Procedure.identifier.valuewill store this sequence number withhttps://fhir.synapxe.sg/NamingSystem/sequence-noas its name space (Procedure.identifier.system)There are two categories of devices documented in the OT Notes that uses the Device resource. First category are devices used during the procedures performed on the patient which are stored in
Composition.section.entry. Second category are focal devices implanted or removed from the patient which are stored inProcedure.focalDevice.manipulated.
Resource Structure
| OTNotes (Composition) | C | Composition | There are no (further) constraints on this element Element idCompositionShort description A set of resources composed into a single coherent clinical statement with clinical attestation DefinitionA set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idComposition.idShort description 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. Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case. |
| meta | Σ | 0..1 | Meta | Element idComposition.metaShort description Metadata about a resource DefinitionThe metadata about a resource. This is content in the resource 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.implicitRulesShort description 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 its 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.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). IETF language tag for a human language
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| text | C | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.textShort description 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 a 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. The cardinality or value of this element may be affected by these constraints: dom-6 Constraints
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| contained | C | 0..* | Resource | There are no (further) constraints on this element Element idComposition.containedShort description 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, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning. 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. The cardinality or value of this element may be affected by these constraints: dom-2, dom-4, dom-3, dom-5 Mappings
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| extension | C | 1..* | Extension | There are no (further) constraints on this element Element idComposition.extensionShort description 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 managable, 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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| displayMethod | C | 1..1 | Extension(string) | Element idComposition.extension:displayMethodShort description Display Method Information Alternate namesextensions, user content DefinitionExtension for capturing display method information 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. https://fhir.synapxe.sg/StructureDefinition/ext-displayMethod Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idComposition.modifierExtensionShort description 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 managable, 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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| url | Σ | 0..1 | uri | There are no (further) constraints on this element Element idComposition.urlShort description Canonical identifier for this Composition, represented as a URI (globally unique) DefinitionAn absolute URI that is used to identify this Composition when it is referenced in a specification, model, design or an instance; also called its canonical identifier. This SHOULD be globally unique and SHOULD be a literal address at which an authoritative instance of this Composition is (or will be) published. This URL can be the target of a canonical reference. It SHALL remain the same when the Composition is stored on different servers. Allows the Composition to be referenced by a single globally unique identifier. Can be a urn:uuid: or a urn:oid: but real http: addresses are preferred. Multiple instances may share the same URL if they have a distinct version.
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| identifier | Σ C | 1..* | Identifier | Element idComposition.identifierShort description 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. Unordered, Open, by system(Value) Constraints
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| (All Slices) | The requirements in this element apply to all slices | |||
| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idComposition.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idComposition.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idComposition.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idComposition.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| recordID | Σ C | 1..1 | Identifier | There are no (further) constraints on this element Element idComposition.identifier:recordIDShort description 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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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.identifier:recordID.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.identifier:recordID.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idComposition.identifier:recordID.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.identifier:recordID.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriPattern | Element idComposition.identifier:recordID.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/record-idExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.identifier:recordID.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idComposition.identifier:recordID.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idComposition.identifier:recordID.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| accessionNumber | Σ C | 1..1 | Identifier | There are no (further) constraints on this element Element idComposition.identifier:accessionNumberShort description 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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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.identifier:accessionNumber.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.identifier:accessionNumber.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idComposition.identifier:accessionNumber.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.identifier:accessionNumber.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriPattern | Element idComposition.identifier:accessionNumber.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/accession-noExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.identifier:accessionNumber.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idComposition.identifier:accessionNumber.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idComposition.identifier:accessionNumber.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.versionShort description An explicitly assigned identifer of a variation of the content in the Composition DefinitionAn explicitly assigned identifer of a variation of the content in the Composition. 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.
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| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idComposition.statusShort description registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown 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 | Σ | 1..1 | CodeableConceptBinding | Element idComposition.typeShort description 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. Key metadata element describing the composition, used in searching/filtering. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Type of a composition. FHIRDocumentTypeCodes (preferred) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.type.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.type.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idComposition.type.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.type.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.type.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.type.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | codePattern | Element idComposition.type.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
11504-8Mappings
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.type.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.type.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.type.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| category | Σ | 0..0 | CodeableConcept | There are no (further) constraints on this element Element idComposition.categoryShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. High-level kind of a clinical document at a macro level. ReferencedItemCategoryValueSet (example) Constraints
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| subject | Σ C | 1..1 | Reference(Patient) | Element idComposition.subjectShort description A reference from one resource to another DefinitionA reference from one resource to another. Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.subject.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.subject.extensionShort description 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 managable, 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 | Σ C | 0..0 | string | There are no (further) constraints on this element Element idComposition.subject.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 1..1 | uriBindingFixed Value | There are no (further) constraints on this element Element idComposition.subject.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
PatientMappings
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| identifier | Σ C | 1..1 | Identifier | There are no (further) constraints on this element Element idComposition.subject.identifierShort description An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.subject.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.subject.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idComposition.subject.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.subject.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idComposition.subject.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/nricExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.subject.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idComposition.subject.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idComposition.subject.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| display | Σ C | 0..0 | string | There are no (further) constraints on this element Element idComposition.subject.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| encounter | Σ C | 1..1 | Reference(Encounter) | Element idComposition.encounterShort description A reference from one resource to another DefinitionA reference from one resource to another. Provides context for the composition and supports searching. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.encounter.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.encounter.extensionShort description 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 managable, 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 | Σ C | 0..0 | string | There are no (further) constraints on this element Element idComposition.encounter.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 1..1 | uriBindingFixed Value | There are no (further) constraints on this element Element idComposition.encounter.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
EncounterMappings
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| identifier | Σ C | 1..1 | Identifier | There are no (further) constraints on this element Element idComposition.encounter.identifierShort description An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.encounter.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.encounter.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idComposition.encounter.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.encounter.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idComposition.encounter.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/event-idExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.encounter.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idComposition.encounter.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idComposition.encounter.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| display | Σ C | 0..0 | string | There are no (further) constraints on this element Element idComposition.encounter.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| date | Σ | 1..1 | dateTime | There are no (further) constraints on this element Element idComposition.dateShort description 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 this version of the Composition. 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. This means that the date on an amended document is the date of the amendment, not the date of original authorship.
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| useContext | Σ | 0..0 | UsageContext | There are no (further) constraints on this element Element idComposition.useContextShort description The context that the content is intended to support DefinitionThe content was developed with a focus and intent of supporting the contexts that are listed. These contexts may be general categories (gender, age, ...) or may be references to specific programs (insurance plans, studies, ...) and may be used to assist with indexing and searching for appropriate Composition instances. Assist in searching for appropriate content. When multiple useContexts are specified, there is no expectation that all or any of the contexts apply.
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| author | Σ C | 1..* | Reference(Practitioner) | Element idComposition.authorShort description Who and/or what authored the composition DefinitionIdentifies who is responsible for the information in the composition, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| id | 0..1 | string | There are no (further) constraints on this element Element idComposition.author.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idComposition.author.extensionShort description 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 managable, 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 | Σ C | 0..0 | string | There are no (further) constraints on this element Element idComposition.author.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 1..1 | uriBindingFixed Value | Element idComposition.author.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
PractitionerMappings
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| identifier | Σ C | 1..1 | Identifier | Element idComposition.author.identifierShort description An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.author.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.author.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idComposition.author.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.author.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.author.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/mcrExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.author.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idComposition.author.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idComposition.author.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| display | Σ C | 0..0 | string | There are no (further) constraints on this element Element idComposition.author.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| name | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.nameShort description Name for this Composition (computer friendly) DefinitionA natural language name identifying the {{title}}. This name should be usable as an identifier for the module by machine processing applications such as code generation. Support human navigation and code generation. The name is not expected to be globally unique. The name should be a simple alphanumeric type name to ensure that it is machine-processing friendly.
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| title | Σ | 1..1 | stringFixed Value | Element idComposition.titleShort description Human Readable name/title DefinitionOfficial human-readable label for the composition. For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.
Operating Theatre (OT) NotesMappings
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| note | 0..1 | Annotation | Element idComposition.noteShort description Text node with attribution DefinitionA text note which also contains information about who made the statement and when. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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| attester | 0..0 | BackboneElement | There are no (further) constraints on this element Element idComposition.attesterShort description Attests to accuracy of composition DefinitionA participant who has attested to the accuracy of the composition/document. Identifies responsibility for the accuracy of the composition content. Only list each attester once.
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| custodian | Σ C | 0..1 | Reference(Organization) | Element idComposition.custodianShort description 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.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.custodian.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.custodian.extensionShort description 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 managable, 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 | Σ C | 0..0 | string | There are no (further) constraints on this element Element idComposition.custodian.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 0..1 | uriBindingFixed Value | Element idComposition.custodian.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
OrganizationMappings
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| identifier | Σ C | 1..1 | Identifier | Element idComposition.custodian.identifierShort description An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.custodian.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.custodian.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idComposition.custodian.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.custodian.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.custodian.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/hci-codeExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.custodian.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idComposition.custodian.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idComposition.custodian.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| display | Σ C | 0..0 | string | There are no (further) constraints on this element Element idComposition.custodian.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| relatesTo | 0..0 | RelatedArtifact | Element idComposition.relatesToShort description Related artifacts for a knowledge resource DefinitionRelated artifacts such as additional documentation, justification, or bibliographic references. Each related artifact is either an attachment, or a reference to another knowledge resource, but not both.
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| event | Σ | 0..0 | BackboneElement | There are no (further) constraints on this element Element idComposition.eventShort description The clinical service(s) being documented DefinitionThe clinical service, such as a colonoscopy or an appendectomy, being documented. Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. The event needs to be consistent with the type element, though can provide further information if desired.
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| section | C | 0..* | BackboneElement | Element idComposition.sectionShort description Composition is broken into sections DefinitionThe root of the sections that make up the composition. Unordered, Open, by code.coding.code(Value) Constraints
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| (All Slices) | The requirements in this element apply to all slices | |||
| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section.modifierExtensionShort description 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 managable, 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.titleShort description Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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| code | 1..1 | CodeableConceptBinding | Element idComposition.section.codeShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Classification of a section of a composition/document. DocSectionCodeValueSet (required) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section.code.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section.code.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idComposition.section.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section.code.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section.code.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idComposition.section.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.section.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idComposition.section.code.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.section.code.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.section.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.section.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| author | C | 0..0 | Reference(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idComposition.section.authorShort description 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 resolvable (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(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Constraints
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| focus | C | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section.focusShort description 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 | C | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section.textShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-1 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section.text.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section.text.extensionShort description 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 managable, 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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| status | 1..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section.text.statusShort description generated | extensions | additional | empty DefinitionThe status of the narrative - whether it's entirely generated (from just the defined data or the extensions too), or whether a human authored it and it may contain additional data. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The status of a resource narrative.
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| div | C | 1..1 | xhtml | There are no (further) constraints on this element Element idComposition.section.text.divShort description Limited xhtml content DefinitionThe actual narrative content, a stripped down version of XHTML. The contents of the html element are an XHTML fragment containing only the basic html formatting elements described in chapters 7-11 and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained stylesheets. The XHTML content SHALL NOT contain a head, a body, external stylesheet references, scripts, forms, base/link/xlink, frames, iframes and objects.
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| orderedBy | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section.orderedByShort description 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 | C | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section.entryShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-1, cmp-2 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section.entry.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section.entry.extensionShort description 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 managable, 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 | Σ C | 0..1 | string | There are no (further) constraints on this element Element idComposition.section.entry.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idComposition.section.entry.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ C | 0..1 | Identifier | There are no (further) constraints on this element Element idComposition.section.entry.identifierShort description 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). This element only allows for a single identifier. In the case where additional identifers are required, use the http://hl7.org/fhir/StructureDefinition/additionalIdentifier extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| display | Σ C | 0..1 | string | There are no (further) constraints on this element Element idComposition.section.entry.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| emptyReason | C | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section.emptyReasonShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-2 Constraints
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| section | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section.sectionShort description Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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| Procedures | C | 0..1 | BackboneElement | There are no (further) constraints on this element Element idComposition.section:ProceduresShort description Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Procedures.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Procedures.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Procedures.modifierExtensionShort description 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 managable, 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..0 | stringFixed Value | Element idComposition.section:Procedures.titleShort description 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.
ProceduresMappings
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| code | 1..1 | CodeableConcept | CodeableConceptBinding | Element idComposition.section:Procedures.codeShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. CodeableConcept | CodeableConcept BindingClassification of a section of a composition/document. DocSectionCodeValueSet (required) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Procedures.code.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Procedures.code.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idComposition.section:Procedures.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Procedures.code.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Procedures.code.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.section:Procedures.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:Procedures.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | codePattern | Element idComposition.section:Procedures.code.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
29554-3Mappings
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:Procedures.code.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.section:Procedures.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Procedures.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| author | C | 0..0 | Reference(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idComposition.section:Procedures.authorShort description 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 resolvable (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(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Constraints
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| focus | C | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:Procedures.focusShort description 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 | C | 1..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:Procedures.textShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-1 Constraints
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| orderedBy | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:Procedures.orderedByShort description 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 | C | 1..* | Reference(Procedure) | Element idComposition.section:Procedures.entryShort description 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. Allowed aggregation:bundled ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1, cmp-2 Constraints
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| emptyReason | C | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:Procedures.emptyReasonShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-2 Constraints
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| section | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:Procedures.sectionShort description 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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| Practitioners | C | 0..1 | BackboneElement | There are no (further) constraints on this element Element idComposition.section:PractitionersShort description Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Practitioners.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Practitioners.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Practitioners.modifierExtensionShort description 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 managable, 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..0 | stringFixed Value | Element idComposition.section:Practitioners.titleShort description 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.
vitalSignsMappings
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| code | 1..1 | CodeableConcept | CodeableConceptBinding | Element idComposition.section:Practitioners.codeShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. CodeableConcept | CodeableConcept BindingClassification of a section of a composition/document. DocSectionCodeValueSet (required) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Practitioners.code.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Practitioners.code.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idComposition.section:Practitioners.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Practitioners.code.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Practitioners.code.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.section:Practitioners.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:Practitioners.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | codePattern | Element idComposition.section:Practitioners.code.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
85847-2Mappings
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:Practitioners.code.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.section:Practitioners.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Practitioners.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| author | C | 0..0 | Reference(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idComposition.section:Practitioners.authorShort description 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 resolvable (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(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Constraints
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| focus | C | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:Practitioners.focusShort description 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 | C | 1..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:Practitioners.textShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-1 Constraints
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| orderedBy | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:Practitioners.orderedByShort description 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 | C | 1..1 | Reference(PractitionerRole) | Element idComposition.section:Practitioners.entryShort description 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. Allowed aggregation:bundled ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1, cmp-2 Constraints
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| emptyReason | C | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:Practitioners.emptyReasonShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-2 Constraints
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| section | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:Practitioners.sectionShort description 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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| Conditions | C | 0..1 | BackboneElement | There are no (further) constraints on this element Element idComposition.section:ConditionsShort description Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Conditions.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Conditions.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Conditions.modifierExtensionShort description 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 managable, 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..0 | stringFixed Value | Element idComposition.section:Conditions.titleShort description 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.
Medication OrdersMappings
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| code | 1..1 | CodeableConcept | CodeableConceptBinding | Element idComposition.section:Conditions.codeShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. CodeableConcept | CodeableConcept BindingClassification of a section of a composition/document. DocSectionCodeValueSet (required) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Conditions.code.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Conditions.code.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idComposition.section:Conditions.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Conditions.code.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Conditions.code.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.section:Conditions.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:Conditions.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | codePattern | Element idComposition.section:Conditions.code.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
29548-5Mappings
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:Conditions.code.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.section:Conditions.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Conditions.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| author | C | 0..0 | Reference(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idComposition.section:Conditions.authorShort description 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 resolvable (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(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Constraints
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| focus | C | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:Conditions.focusShort description 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 | C | 1..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:Conditions.textShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-1 Constraints
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| orderedBy | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:Conditions.orderedByShort description 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 | C | 1..* | Reference(Condition) | Element idComposition.section:Conditions.entryShort description 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. Allowed aggregation:bundled ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1, cmp-2 Constraints
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| emptyReason | C | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:Conditions.emptyReasonShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-2 Constraints
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| section | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:Conditions.sectionShort description 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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| Observations | C | 0..1 | BackboneElement | There are no (further) constraints on this element Element idComposition.section:ObservationsShort description Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Observations.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Observations.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Observations.modifierExtensionShort description 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 managable, 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..0 | stringFixed Value | Element idComposition.section:Observations.titleShort description 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.
Infusion OrdersMappings
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| code | 1..1 | CodeableConcept | CodeableConceptBinding | Element idComposition.section:Observations.codeShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. CodeableConcept | CodeableConcept BindingClassification of a section of a composition/document. DocSectionCodeValueSet (required) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Observations.code.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Observations.code.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idComposition.section:Observations.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Observations.code.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Observations.code.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.section:Observations.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:Observations.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | codePattern | Element idComposition.section:Observations.code.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
8716-3Mappings
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:Observations.code.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.section:Observations.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Observations.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| author | C | 0..0 | Reference(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idComposition.section:Observations.authorShort description 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 resolvable (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(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Constraints
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| focus | C | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:Observations.focusShort description 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 | C | 1..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:Observations.textShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-1 Constraints
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| orderedBy | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:Observations.orderedByShort description 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 | C | 1..* | Reference(Observation) | Element idComposition.section:Observations.entryShort description 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. Allowed aggregation:bundled ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1, cmp-2 Constraints
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| emptyReason | C | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:Observations.emptyReasonShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-2 Constraints
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| section | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:Observations.sectionShort description 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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| MedicationAdministrations | C | 0..1 | BackboneElement | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrationsShort description Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.modifierExtensionShort description 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 managable, 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..0 | stringFixed Value | Element idComposition.section:MedicationAdministrations.titleShort description 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.
Procedure OrdersMappings
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| code | 1..1 | CodeableConcept | CodeableConceptBinding | Element idComposition.section:MedicationAdministrations.codeShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. CodeableConcept | CodeableConcept BindingClassification of a section of a composition/document. DocSectionCodeValueSet (required) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.code.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.code.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.code.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.code.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.section:MedicationAdministrations.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | codePattern | Element idComposition.section:MedicationAdministrations.code.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
29549-3Mappings
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.code.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| author | C | 0..0 | Reference(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.authorShort description 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 resolvable (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(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Constraints
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| focus | C | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.focusShort description 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 | C | 1..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.textShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-1 Constraints
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| orderedBy | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.orderedByShort description 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 | C | 1..* | Reference(MedicationAdministration) | Element idComposition.section:MedicationAdministrations.entryShort description 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(MedicationAdministration) Allowed aggregation:bundled ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1, cmp-2 Constraints
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| emptyReason | C | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.emptyReasonShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-2 Constraints
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| section | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:MedicationAdministrations.sectionShort description 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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| Devices | C | 0..1 | BackboneElement | There are no (further) constraints on this element Element idComposition.section:DevicesShort description Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Devices.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Devices.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Devices.modifierExtensionShort description 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 managable, 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..0 | stringFixed Value | Element idComposition.section:Devices.titleShort description 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.
Prescription OrdersMappings
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| code | 1..1 | CodeableConcept | CodeableConceptBinding | Element idComposition.section:Devices.codeShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. CodeableConcept | CodeableConcept BindingClassification of a section of a composition/document. DocSectionCodeValueSet (required) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Devices.code.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Devices.code.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idComposition.section:Devices.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Devices.code.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Devices.code.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.section:Devices.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:Devices.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | codePattern | Element idComposition.section:Devices.code.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
46264-8Mappings
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:Devices.code.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.section:Devices.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Devices.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| author | C | 0..0 | Reference(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idComposition.section:Devices.authorShort description 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 resolvable (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(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Constraints
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| focus | C | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:Devices.focusShort description 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 | C | 1..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:Devices.textShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-1 Constraints
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| orderedBy | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:Devices.orderedByShort description 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 | C | 1..* | Reference(Device) | Element idComposition.section:Devices.entryShort description 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. Allowed aggregation:bundled ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1, cmp-2 Constraints
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| emptyReason | C | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:Devices.emptyReasonShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-2 Constraints
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| section | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:Devices.sectionShort description 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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| DiagnosticReports | C | 0..1 | BackboneElement | There are no (further) constraints on this element Element idComposition.section:DiagnosticReportsShort description Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.modifierExtensionShort description 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 managable, 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..0 | stringFixed Value | Element idComposition.section:DiagnosticReports.titleShort description 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.
Diagnostic ReportsMappings
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| code | 1..1 | CodeableConcept | CodeableConceptBinding | Element idComposition.section:DiagnosticReports.codeShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. CodeableConcept | CodeableConcept BindingClassification of a section of a composition/document. DocSectionCodeValueSet (required) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.code.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.code.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.code.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.code.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.section:DiagnosticReports.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | codePattern | Element idComposition.section:DiagnosticReports.code.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
34895-3Mappings
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.code.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| author | C | 0..0 | Reference(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.authorShort description 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 resolvable (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(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Constraints
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| focus | C | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.focusShort description 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 | C | 1..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.textShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-1 Constraints
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| orderedBy | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.orderedByShort description 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 | C | 1..* | Reference(DiagnosticReport) | Element idComposition.section:DiagnosticReports.entryShort description 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. Allowed aggregation:bundled ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1, cmp-2 Constraints
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| emptyReason | C | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.emptyReasonShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-2 Constraints
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| section | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:DiagnosticReports.sectionShort description 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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| Specimens | C | 0..1 | BackboneElement | There are no (further) constraints on this element Element idComposition.section:SpecimensShort description Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Specimens.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Specimens.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Specimens.modifierExtensionShort description 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 managable, 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..0 | stringFixed Value | Element idComposition.section:Specimens.titleShort description 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.
SpecimensMappings
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| code | 1..1 | CodeableConcept | CodeableConceptBinding | Element idComposition.section:Specimens.codeShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. CodeableConcept | CodeableConcept BindingClassification of a section of a composition/document. DocSectionCodeValueSet (required) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Specimens.code.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Specimens.code.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idComposition.section:Specimens.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Specimens.code.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:Specimens.code.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.section:Specimens.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:Specimens.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | codePattern | Element idComposition.section:Specimens.code.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
59773-2Mappings
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:Specimens.code.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.section:Specimens.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:Specimens.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| author | C | 0..0 | Reference(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idComposition.section:Specimens.authorShort description 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 resolvable (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(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Constraints
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| focus | C | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:Specimens.focusShort description 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 | C | 1..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:Specimens.textShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-1 Constraints
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| orderedBy | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:Specimens.orderedByShort description 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 | C | 1..* | Reference(Specimen) | Element idComposition.section:Specimens.entryShort description 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. Allowed aggregation:bundled ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1, cmp-2 Constraints
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| emptyReason | C | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:Specimens.emptyReasonShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-2 Constraints
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| section | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:Specimens.sectionShort description 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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| FileAttachments | C | 0..* | BackboneElement | There are no (further) constraints on this element Element idComposition.section:FileAttachmentsShort description Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:FileAttachments.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:FileAttachments.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:FileAttachments.modifierExtensionShort description 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 managable, 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..0 | stringFixed Value | Element idComposition.section:FileAttachments.titleShort description 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.
FileAttachmentsMappings
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| code | 1..1 | CodeableConcept | CodeableConceptBinding | Element idComposition.section:FileAttachments.codeShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. CodeableConcept | CodeableConcept BindingClassification of a section of a composition/document. DocSectionCodeValueSet (required) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:FileAttachments.code.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:FileAttachments.code.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idComposition.section:FileAttachments.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:FileAttachments.code.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idComposition.section:FileAttachments.code.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idComposition.section:FileAttachments.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:FileAttachments.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | codePattern | Element idComposition.section:FileAttachments.code.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
28570-0Mappings
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idComposition.section:FileAttachments.code.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idComposition.section:FileAttachments.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idComposition.section:FileAttachments.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| author | C | 0..0 | Reference(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idComposition.section:FileAttachments.authorShort description 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 resolvable (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(Device | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) Constraints
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| focus | C | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:FileAttachments.focusShort description 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 | C | 0..0 | Narrative | There are no (further) constraints on this element Element idComposition.section:FileAttachments.textShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-1 Constraints
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| orderedBy | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:FileAttachments.orderedByShort description 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 | C | 1..1 | Reference(FileAttachment) | Element idComposition.section:FileAttachments.entryShort description 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. Allowed aggregation:bundled ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1, cmp-2 Constraints
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| emptyReason | C | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:FileAttachments.emptyReasonShort description 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. The cardinality or value of this element may be affected by these constraints: cmp-2 Constraints
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| section | 0..0 | see (section) | There are no (further) constraints on this element Element idComposition.section:FileAttachments.sectionShort description 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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| Observation | C | Observation | There are no (further) constraints on this element Element idObservationShort description Measurements and simple assertions Alternate namesVital Signs, Measurement, Results, Tests DefinitionMeasurements and simple assertions made about a patient, device or other subject. Used for simple observations such as device measurements, laboratory atomic results, vital signs, height, weight, smoking status, comments, etc. Other resources are used to provide context for observations such as laboratory reports, etc.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idObservation.idShort description 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. Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idObservation.metaShort description 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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| id | 0..1 | string | There are no (further) constraints on this element Element idObservation.meta.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idObservation.meta.extensionShort description 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 managable, 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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| versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idObservation.meta.versionIdShort description Version specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
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| lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element idObservation.meta.lastUpdatedShort description When the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed. This element is generally omitted in instances submitted in a PUT or POST. Instead, it is populated in the response instance and when retrieving information using a GET. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
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| source | Σ | 0..1 | uri | There are no (further) constraints on this element Element idObservation.meta.sourceShort description Identifies where the resource comes from DefinitionA uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. The exact use of the source (and the possible implied Provenance.entity.role and agent.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. The source may correspond to Provenance.entity.what[x] or Provenance.agent.who[x], though it may be a more general or abstract reference. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
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| profile | Σ | 1..1 | canonical(StructureDefinition)Fixed Value | Element idObservation.meta.profileShort description Profiles this resource claims to conform to DefinitionA list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. canonical(StructureDefinition) Constraints
https://fhir.synapxe.sg/StructureDefinition/profile-ot-observationMappings
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| security | Σ C | 0..* | CodingBinding | There are no (further) constraints on this element Element idObservation.meta.securityShort description Security Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. Security Labels from the Healthcare Privacy and Security Classification System. AllSecurityLabels (extensible) Constraints
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| tag | Σ C | 0..* | Coding | There are no (further) constraints on this element Element idObservation.meta.tagShort description Tags applied to this resource DefinitionTags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource. The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idObservation.implicitRulesShort description 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 its 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 idObservation.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). IETF language tag for a human language
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| text | C | 0..1 | Narrative | There are no (further) constraints on this element Element idObservation.textShort description 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 a 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. The cardinality or value of this element may be affected by these constraints: dom-6 Constraints
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| contained | C | 0..* | Resource | There are no (further) constraints on this element Element idObservation.containedShort description 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, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning. 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. The cardinality or value of this element may be affected by these constraints: dom-2, dom-4, dom-3, dom-5 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idObservation.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.modifierExtensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| identifier | Σ C | 1..1 | Identifier | Element idObservation.identifierShort description An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. Allows observations to be distinguished and referenced. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.
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| id | 0..0 | string | There are no (further) constraints on this element Element idObservation.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idObservation.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idObservation.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/sequence-noExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idObservation.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idObservation.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idObservation.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| instantiates[x] | Σ | 0..0 | There are no (further) constraints on this element Element idObservation.instantiates[x]Short description Instantiates FHIR ObservationDefinition DefinitionThe reference to a FHIR ObservationDefinition resource that provides the definition that is adhered to in whole or in part by this Observation instance. ObservationDefinition can be referenced by its canonical url using instantiatesCanonical, or by a name or an identifier using the appropriate sub-elements of instantiatesReference.
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| basedOn | Σ C | 0..0 | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | There are no (further) constraints on this element Element idObservation.basedOnShort description Fulfills plan, proposal or order Alternate namesFulfills DefinitionA plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed. Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Constraints
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| triggeredBy | 0..0 | BackboneElement | There are no (further) constraints on this element Element idObservation.triggeredByShort description Triggering observation(s) DefinitionIdentifies the observation(s) that triggered the performance of this observation.
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| partOf | Σ C | 0..0 | Reference(GenomicStudy | ImagingStudy | Immunization | MedicationAdministration | MedicationDispense | MedicationStatement | Procedure) | There are no (further) constraints on this element Element idObservation.partOfShort description Part of referenced event Alternate namesContainer DefinitionA larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure. To link an Observation to an Encounter use Reference(GenomicStudy | ImagingStudy | Immunization | MedicationAdministration | MedicationDispense | MedicationStatement | Procedure) Constraints
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| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idObservation.statusShort description registered | preliminary | final | amended + DefinitionThe status of the result value. Need to track the status of individual results. Some results are finalized before the whole report is finalized. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Codes providing the status of an observation.
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| category | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.categoryShort description Classification of type of observation DefinitionA code that classifies the general type of observation being made. Used for filtering what observations are retrieved and displayed. In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. Codes for high level observation categories. ObservationCategoryCodes (preferred) Constraints
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| code | Σ C | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idObservation.codeShort description Type of observation (code / type) Alternate namesName DefinitionDescribes what was observed. Sometimes this is called the observation "name". Knowing what kind of observation is being made is essential to understanding the observation. All code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation. Codes identifying names of simple observations. The cardinality or value of this element may be affected by these constraints: obs-7 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idObservation.code.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.code.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..1 | Coding | There are no (further) constraints on this element Element idObservation.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idObservation.code.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.code.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idObservation.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idObservation.code.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idObservation.code.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idObservation.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idObservation.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| subject | Σ C | 0..0 | Reference(BiologicallyDerivedProduct | Device | Group | Location | Medication | NutritionProduct | Organization | Patient | Practitioner | Procedure | Substance) | There are no (further) constraints on this element Element idObservation.subjectShort description Who and/or what the observation is about DefinitionThe patient, or group of patients, location, device, organization, procedure or practitioner this observation is about and into whose or what record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the Observations have no value if you don't know who or what they're about. One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated. The subject of an Observation may in some cases be a procedure. This supports the regulatory inspection use case where observations are captured during inspections of a procedure that is being performed (independent of any particular patient or whether patient related at all). Reference(BiologicallyDerivedProduct | Device | Group | Location | Medication | NutritionProduct | Organization | Patient | Practitioner | Procedure | Substance) Constraints
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| focus | Σ C | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idObservation.focusShort description What the observation is about, when it is not about the subject of record DefinitionThe actual focus of an observation when it is not the patient of record representing something or someone associated with the patient such as a spouse, parent, fetus, or donor. For example, fetus observations in a mother's record. The focus of an observation could also be an existing condition, an intervention, the subject's diet, another observation of the subject, or a body structure such as tumor or implanted device. An example use case would be using the Observation resource to capture whether the mother is trained to change her child's tracheostomy tube. In this example, the child is the patient of record and the mother is the focus. Typically, an observation is made about the subject - a patient, or group of patients, location, or device - and the distinction between the subject and what is directly measured for an observation is specified in the observation code itself ( e.g., "Blood Glucose") and does not need to be represented separately using this element. Use
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| encounter | Σ C | 0..0 | Reference(Encounter) | There are no (further) constraints on this element Element idObservation.encounterShort description Healthcare event during which this observation is made Alternate namesContext DefinitionThe healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made. For some observations it may be important to know the link between an observation and a particular encounter. This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
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| effective[x] | Σ | 0..0 | There are no (further) constraints on this element Element idObservation.effective[x]Short description Clinically relevant time/time-period for observation Alternate namesOccurrence DefinitionThe time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself. Knowing when an observation was deemed true is important to its relevance as well as determining trends. At least a date should be present unless this observation is a historical report. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events.
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| issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idObservation.issuedShort description Date/Time this version was made available DefinitionThe date and time this version of the observation was made available to providers, typically after the results have been reviewed and verified. For Observations that don't require review and verification, it may be the same as the
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| performer | Σ C | 0..0 | Reference(Practitioner) | Element idObservation.performerShort description Who is responsible for the observation DefinitionWho was responsible for asserting the observed value as "true". May give a degree of confidence in the observation and also indicates where follow-up questions should be directed. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| value[x] | Σ C | 0..1 | There are no (further) constraints on this element Element idObservation.value[x]Short description Actual result DefinitionThe information determined as a result of making the observation, if the information has a simple value. An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations.
The cardinality or value of this element may be affected by these constraints: obs-7, obs-6 Constraints
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| valueCodeableConcept | CodeableConcept | Data type | ||
| valueQuantity | Quantity | Data type | ||
| dataAbsentReason | C | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.dataAbsentReasonShort description Why the result is missing DefinitionProvides a reason why the expected value in the element Observation.value[x] is missing. For many results it is necessary to handle exceptional values in measurements. Null or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "specimen unsatisfactory". The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Note that an observation may only be reported if there are values to report. For example differential cell counts values may be reported only when > 0. Because of these options, use-case agreements are required to interpret general observations for null or exceptional values. Codes specifying why the result ( The cardinality or value of this element may be affected by these constraints: obs-6 Constraints
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| interpretation | 0..1 | CodeableConceptBinding | Element idObservation.interpretationShort description Concept - reference to a terminology or just text Alternate namesAbnormal Flag DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes identifying interpretations of observations. ObservationInterpretationCodes (extensible) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idObservation.interpretation.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.interpretation.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idObservation.interpretation.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.interpretation.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idObservation.interpretation.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idObservation.interpretation.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idObservation.interpretation.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idObservation.interpretation.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idObservation.interpretation.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| note | 0..1 | Annotation | There are no (further) constraints on this element Element idObservation.noteShort description Comments about the observation DefinitionComments about the observation or the results. Need to be able to provide free text additional information. May include general statements about the observation, or statements about significant, unexpected or unreliable results values, or information about its source when relevant to its interpretation.
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| id | 0..0 | string | There are no (further) constraints on this element Element idObservation.note.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.note.extensionShort description 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 managable, 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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| author[x] | Σ | 0..0 | There are no (further) constraints on this element Element idObservation.note.author[x]Short description Individual responsible for the annotation DefinitionThe individual responsible for making the annotation. Organization is used when there's no need for specific attribution as to who made the comment.
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| time | Σ | 0..0 | dateTime | There are no (further) constraints on this element Element idObservation.note.timeShort description When the annotation was made DefinitionIndicates when this particular annotation was made. UTC offset is allowed for dates and partial dates
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| text | Σ | 1..1 | markdown | There are no (further) constraints on this element Element idObservation.note.textShort description The annotation - text content (as markdown) DefinitionThe text of the annotation in markdown format. Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/
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| bodySite | C | 0..0 | CodeableConcept | Element idObservation.bodySiteShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. SNOMED CT Body site concepts SNOMEDCTBodyStructures (example) ConditionsThe cardinality or value of this element may be affected by these constraints: obs-8 Constraints
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| bodyStructure | C | 0..0 | Reference(BodyStructure) | There are no (further) constraints on this element Element idObservation.bodyStructureShort description Observed body structure DefinitionIndicates the body structure on the subject's body where the observation was made (i.e. the target site). Only used if not implicit in code found in Observation.code or bodySite is used. In many systems, this may be represented as a related observation instead of an inline component. The cardinality or value of this element may be affected by these constraints: obs-8 Constraints
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| method | 0..1 | CodeableConcept | Element idObservation.methodShort description 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. In some cases, method can impact results and is thus used for determining whether results can be compared or determining significance of results. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Methods for simple observations.
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| id | 0..0 | string | There are no (further) constraints on this element Element idObservation.method.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.method.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idObservation.method.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idObservation.method.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.method.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idObservation.method.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
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| version | Σ | 0..0 | string | There are no (further) constraints on this element Element idObservation.method.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idObservation.method.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idObservation.method.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idObservation.method.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idObservation.method.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| specimen | C | 0..0 | Reference(Specimen) | Element idObservation.specimenShort description Specimen used for this observation DefinitionThe specimen that was used when this observation was made. Should only be used if not implicit in code found in
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| device | C | 0..0 | Reference(Device) | Element idObservation.deviceShort description A reference to the device that generates the measurements or the device settings for the device DefinitionA reference to the device that generates the measurements or the device settings for the device. Note that this is not meant to represent a device involved in the transmission of the result, e.g., a gateway. Such devices may be documented using the Provenance resource where relevant.
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| referenceRange | C | 0..1 | BackboneElement | There are no (further) constraints on this element Element idObservation.referenceRangeShort description Provides guide for interpretation DefinitionGuidance on how to interpret the value by comparison to a normal or recommended range. Multiple reference ranges are interpreted as an "OR". In other words, to represent two distinct target populations, two Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts. Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties.
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| id | 0..0 | string | There are no (further) constraints on this element Element idObservation.referenceRange.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.referenceRange.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.referenceRange.modifierExtensionShort description 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 managable, 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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| low | C | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idObservation.referenceRange.lowShort description Low Range, if relevant DefinitionThe value of the low bound of the reference range. The low bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the low bound is omitted, it is assumed to be meaningless (e.g. reference range is <=2.3). The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator. The cardinality or value of this element may be affected by these constraints: obs-3 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idObservation.referenceRange.low.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.referenceRange.low.extensionShort description 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 managable, 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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| value | Σ | 1..1 | decimal | There are no (further) constraints on this element Element idObservation.referenceRange.low.valueShort description Numerical value (with implicit precision) DefinitionThe value of the measured amount. The value includes an implicit precision in the presentation of the value. Precision is handled implicitly in almost all cases of measurement. The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).
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| comparator | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idObservation.referenceRange.low.comparatorShort description < | <= | >= | > | ad - how to understand the value DefinitionNot allowed to be used in this context Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size If there is no comparator, then there is no modification of the value How the Quantity should be understood and represented.
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| unit | Σ | 1..1 | string | There are no (further) constraints on this element Element idObservation.referenceRange.low.unitShort description Unit representation DefinitionA human-readable form of the unit. There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size
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| system | Σ C | 0..0 | uri | There are no (further) constraints on this element Element idObservation.referenceRange.low.systemShort description System that defines coded unit form DefinitionThe identification of the system that provides the coded form of the unit. Need to know the system that defines the coded form of the unit. see http://en.wikipedia.org/wiki/Uniform_resource_identifier The cardinality or value of this element may be affected by these constraints: qty-3 Constraints
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| code | Σ C | 0..0 | code | There are no (further) constraints on this element Element idObservation.referenceRange.low.codeShort description Coded form of the unit DefinitionA computer processable form of the unit in some unit representation system. Need a computable form of the unit that is fixed across all forms. UCUM provides this for quantities, but SNOMED CT provides many units of interest. The preferred system is UCUM, but SNOMED CT can also be used (for customary units) or ISO 4217 for currency. The context of use may additionally require a code from a particular system. The cardinality or value of this element may be affected by these constraints: qty-3 Constraints
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| high | C | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idObservation.referenceRange.highShort description High Range, if relevant DefinitionThe value of the high bound of the reference range. The high bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the high bound is omitted, it is assumed to be meaningless (e.g. reference range is >= 2.3). The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator. The cardinality or value of this element may be affected by these constraints: obs-3 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idObservation.referenceRange.high.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.referenceRange.high.extensionShort description 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 managable, 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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| value | Σ | 1..1 | decimal | There are no (further) constraints on this element Element idObservation.referenceRange.high.valueShort description Numerical value (with implicit precision) DefinitionThe value of the measured amount. The value includes an implicit precision in the presentation of the value. Precision is handled implicitly in almost all cases of measurement. The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).
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| comparator | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idObservation.referenceRange.high.comparatorShort description < | <= | >= | > | ad - how to understand the value DefinitionNot allowed to be used in this context Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size If there is no comparator, then there is no modification of the value How the Quantity should be understood and represented.
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| unit | Σ | 1..1 | string | There are no (further) constraints on this element Element idObservation.referenceRange.high.unitShort description Unit representation DefinitionA human-readable form of the unit. There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size
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| system | Σ C | 0..0 | uri | There are no (further) constraints on this element Element idObservation.referenceRange.high.systemShort description System that defines coded unit form DefinitionThe identification of the system that provides the coded form of the unit. Need to know the system that defines the coded form of the unit. see http://en.wikipedia.org/wiki/Uniform_resource_identifier The cardinality or value of this element may be affected by these constraints: qty-3 Constraints
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| code | Σ C | 0..0 | code | There are no (further) constraints on this element Element idObservation.referenceRange.high.codeShort description Coded form of the unit DefinitionA computer processable form of the unit in some unit representation system. Need a computable form of the unit that is fixed across all forms. UCUM provides this for quantities, but SNOMED CT provides many units of interest. The preferred system is UCUM, but SNOMED CT can also be used (for customary units) or ISO 4217 for currency. The context of use may additionally require a code from a particular system. The cardinality or value of this element may be affected by these constraints: qty-3 Constraints
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| normalValue | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idObservation.referenceRange.normalValueShort description Normal value, if relevant DefinitionThe value of the normal value of the reference range. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes identifying the normal value of the observation. ObservationReferenceRangeNormalValueCodes (extensible) Constraints
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| type | 0..1 | CodeableConceptBinding | Element idObservation.referenceRange.typeShort description 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. Need to be able to say what kind of reference range this is - normal, recommended, therapeutic, etc., - for proper interpretation. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Code for the meaning of a reference range. ObservationReferenceRangeMeaningCodes (preferred) Constraints
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| appliesTo | 0..0 | CodeableConcept | There are no (further) constraints on this element Element idObservation.referenceRange.appliesToShort description Reference range population DefinitionCodes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Multiple Need to be able to identify the target population for proper interpretation. This SHOULD be populated if there is more than one range. If this element is not present then the normal population is assumed. Codes identifying the population the reference range applies to. ObservationReferenceRangeAppliesToCodes (example) Constraints
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| age | C | 0..1 | Range | There are no (further) constraints on this element Element idObservation.referenceRange.ageShort description Applicable age range, if relevant DefinitionThe age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so. Some analytes vary greatly over age. The stated low and high value are assumed to have arbitrarily high precision when it comes to determining which values are in the range. I.e. 1.99 is not in the range 2 -> 3.
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| id | 0..0 | string | There are no (further) constraints on this element Element idObservation.referenceRange.age.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idObservation.referenceRange.age.extensionShort description 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 managable, 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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| low | Σ C | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idObservation.referenceRange.age.lowShort description Low limit DefinitionThe low limit. The boundary is inclusive. If the low element is missing, the low boundary is not known. The cardinality or value of this element may be affected by these constraints: rng-2 Constraints
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| high | Σ C | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idObservation.referenceRange.age.highShort description High limit DefinitionThe high limit. The boundary is inclusive. If the high element is missing, the high boundary is not known. The cardinality or value of this element may be affected by these constraints: rng-2 Constraints
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| text | C | 0..1 | markdown | There are no (further) constraints on this element Element idObservation.referenceRange.textShort description Text based reference range in an observation DefinitionText based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of "normals". Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/ The cardinality or value of this element may be affected by these constraints: obs-3 Constraints
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| hasMember | Σ C | 0..0 | Reference(MolecularSequence | Observation | QuestionnaireResponse) | There are no (further) constraints on this element Element idObservation.hasMemberShort description Related resource that belongs to the Observation group DefinitionThis observation is a group observation (e.g. a battery, a panel of tests, a set of vital sign measurements) that includes the target as a member of the group. When using this element, an observation will typically have either a value or a set of related resources, although both may be present in some cases. For a discussion on the ways Observations can assembled in groups together, see Notes below. Note that a system may calculate results from QuestionnaireResponse into a final score and represent the score as an Observation. Reference(MolecularSequence | Observation | QuestionnaireResponse) Constraints
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| derivedFrom | Σ C | 0..0 | Reference(DocumentReference | GenomicStudy | ImagingSelection | ImagingStudy | MolecularSequence | Observation | QuestionnaireResponse) | There are no (further) constraints on this element Element idObservation.derivedFromShort description Related resource from which the observation is made DefinitionThe target resource that represents a measurement from which this observation value is derived. For example, a calculated anion gap or a fetal measurement based on an ultrasound image. All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see Notes below. Reference(DocumentReference | GenomicStudy | ImagingSelection | ImagingStudy | MolecularSequence | Observation | QuestionnaireResponse) Constraints
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| component | Σ C | 0..0 | BackboneElement | There are no (further) constraints on this element Element idObservation.componentShort description Component results DefinitionSome observations have multiple component observations. These component observations are expressed as separate code value pairs that share the same attributes. Examples include systolic and diastolic component observations for blood pressure measurement and multiple component observations for genetics observations. Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation. For a discussion on the ways Observations can be assembled in groups together see Notes below. The cardinality or value of this element may be affected by these constraints: obs-7 Constraints
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| MedicationAdministration | C | MedicationAdministration | There are no (further) constraints on this element Element idMedicationAdministrationShort description Administration of medication to a patient DefinitionDescribes the event of a patient consuming or otherwise being administered a medication. This may be as simple as swallowing a tablet or it may be a long running infusion. Related resources tie this event to the authorizing prescription, and the specific encounter between patient and health care practitioner.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idMedicationAdministration.idShort description 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. Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idMedicationAdministration.metaShort description 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 idMedicationAdministration.implicitRulesShort description 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 its 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 idMedicationAdministration.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). IETF language tag for a human language
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| text | C | 0..1 | Narrative | There are no (further) constraints on this element Element idMedicationAdministration.textShort description 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 a 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. The cardinality or value of this element may be affected by these constraints: dom-6 Constraints
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| contained | C | 0..* | Medication | Element idMedicationAdministration.containedShort description Definition of a Medication Alternate namesinline resources, anonymous resources, contained resources DefinitionThis resource is primarily used for the identification and definition of a medication, including ingredients, for the purposes of prescribing, dispensing, and administering a medication as well as for making statements about medication use. 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. The cardinality or value of this element may be affected by these constraints: dom-2, dom-4, dom-3, dom-5 Constraints
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idMedicationAdministration.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idMedicationAdministration.modifierExtensionShort description 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 managable, 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 | C | 1..1 | Identifier | Element idMedicationAdministration.identifierShort description An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.
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| id | 0..0 | string | There are no (further) constraints on this element Element idMedicationAdministration.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idMedicationAdministration.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idMedicationAdministration.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idMedicationAdministration.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idMedicationAdministration.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/sequence-noExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idMedicationAdministration.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idMedicationAdministration.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idMedicationAdministration.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| basedOn | C | 0..0 | Reference(CarePlan) | There are no (further) constraints on this element Element idMedicationAdministration.basedOnShort description Plan this is fulfilled by this administration DefinitionA plan that is fulfilled in whole or in part by this MedicationAdministration. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| partOf | Σ C | 0..0 | Reference(MedicationAdministration | MedicationDispense | Procedure) | There are no (further) constraints on this element Element idMedicationAdministration.partOfShort description Part of referenced event DefinitionA larger event of which this particular event is a component or step. MedicationDispense will be used to indicate waste. Reference(MedicationAdministration | MedicationDispense | Procedure) Constraints
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| status | Σ ?! | 1..1 | codeBindingPattern | Element idMedicationAdministration.statusShort description in-progress | not-done | on-hold | completed | entered-in-error | stopped | unknown DefinitionWill generally be set to show that the administration has been completed. For some long running administrations such as infusions, it is possible for an administration to be started but not completed or it may be paused while some other process is under way. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. A set of codes indicating the current status of a MedicationAdministration. MedicationAdministrationStatusCodes (required) Constraints
completedMappings
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| statusReason | 0..0 | CodeableConcept | There are no (further) constraints on this element Element idMedicationAdministration.statusReasonShort description Reason administration not performed DefinitionA code indicating why the administration was not performed. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A set of codes indicating the reason why the MedicationAdministration is negated. SNOMEDCTReasonMedicationNotGivenCodes (example) Constraints
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| category | 0..0 | CodeableConcept | There are no (further) constraints on this element Element idMedicationAdministration.categoryShort description Type of medication administration DefinitionThe type of medication administration (for example, drug classification like ATC, where meds would be administered, legal category of the medication). Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A coded concept describing where the medication administered is expected to occur. MedicationAdministrationLocationCodes (example) Constraints
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| medication | Σ | 1..1 | CodeableReference(Medication) | Element idMedicationAdministration.medicationShort description What was administered DefinitionIdentifies the medication that was administered. This is either a link to a resource representing the details of the medication or a simple attribute carrying a code that identifies the medication from a known list of medications. If only a code is specified, then it needs to be a code for a specific product. If more information is required, then the use of the medication resource is recommended. For example, if you require form or lot number, then you must reference the Medication resource. Codes identifying substance or product that can be administered. SNOMEDCTMedicationCodes (example) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idMedicationAdministration.medication.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idMedicationAdministration.medication.extensionShort description 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 managable, 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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| concept | Σ | 1..1 | CodeableConceptBinding | Element idMedicationAdministration.medication.conceptShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| id | 0..0 | string | There are no (further) constraints on this element Element idMedicationAdministration.medication.concept.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idMedicationAdministration.medication.concept.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idMedicationAdministration.medication.concept.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idMedicationAdministration.medication.concept.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idMedicationAdministration.medication.concept.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idMedicationAdministration.medication.concept.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
https://fhir.synapxe.sg/CodeSystem/med-codeMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idMedicationAdministration.medication.concept.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idMedicationAdministration.medication.concept.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idMedicationAdministration.medication.concept.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idMedicationAdministration.medication.concept.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idMedicationAdministration.medication.concept.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| reference | Σ C | 0..0 | Reference | Element idMedicationAdministration.medication.referenceShort description Reference to a resource (by instance) DefinitionA reference to a resource the provides exact details about the information being referenced. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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. Allowed aggregation:contained Constraints
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| subject | Σ C | 1..1 | Reference(Patient) | Element idMedicationAdministration.subjectShort description A reference from one resource to another DefinitionA reference from one resource to another. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| id | 0..0 | string | There are no (further) constraints on this element Element idMedicationAdministration.subject.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idMedicationAdministration.subject.extensionShort description 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 managable, 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 | Σ C | 0..0 | string | There are no (further) constraints on this element Element idMedicationAdministration.subject.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 1..1 | uriBindingFixed Value | There are no (further) constraints on this element Element idMedicationAdministration.subject.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
PatientMappings
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| identifier | Σ C | 1..1 | Identifier | There are no (further) constraints on this element Element idMedicationAdministration.subject.identifierShort description An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idMedicationAdministration.subject.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idMedicationAdministration.subject.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idMedicationAdministration.subject.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idMedicationAdministration.subject.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idMedicationAdministration.subject.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/nricExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idMedicationAdministration.subject.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idMedicationAdministration.subject.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idMedicationAdministration.subject.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| display | Σ C | 0..0 | string | There are no (further) constraints on this element Element idMedicationAdministration.subject.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| encounter | C | 0..0 | Reference(Encounter) | There are no (further) constraints on this element Element idMedicationAdministration.encounterShort description Encounter administered as part of DefinitionThe visit, admission, or other contact between patient and health care provider during which the medication administration was performed. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| supportingInformation | C | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idMedicationAdministration.supportingInformationShort description Additional information to support administration DefinitionAdditional information (for example, patient height and weight) that supports the administration of the medication. This attribute can be used to provide documentation of specific characteristics of the patient present at the time of administration. For example, if the dose says "give "x" if the heartrate exceeds "y"", then the heart rate can be included using this attribute. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| occurence[x] | Σ | 1..1 | There are no (further) constraints on this element Element idMedicationAdministration.occurence[x]Short description Specific date/time or interval of time during which the administration took place (or did not take place) DefinitionA specific date/time or interval of time during which the administration took place (or did not take place). For many administrations, such as swallowing a tablet the use of dateTime is more appropriate.
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| occurenceDateTime | dateTime | Data type | ||
| recorded | Σ | 0..0 | dateTime | There are no (further) constraints on this element Element idMedicationAdministration.recordedShort description When the MedicationAdministration was first captured in the subject's record DefinitionThe date the occurrence of the MedicationAdministration was first captured in the record - potentially significantly after the occurrence of the event. UTC offset is allowed for dates and partial dates
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| isSubPotent | 0..0 | boolean | There are no (further) constraints on this element Element idMedicationAdministration.isSubPotentShort description Full dose was not administered DefinitionAn indication that the full dose was not administered.
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| subPotentReason | 0..0 | CodeableConcept | There are no (further) constraints on this element Element idMedicationAdministration.subPotentReasonShort description Reason full dose was not administered DefinitionThe reason or reasons why the full dose was not administered. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. MedicationAdministrationSubpotentReason (example) Constraints
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| performer | Σ | 0..0 | BackboneElement | There are no (further) constraints on this element Element idMedicationAdministration.performerShort description Who or what performed the medication administration and what type of performance they did DefinitionThe performer of the medication treatment. For devices this is the device that performed the administration of the medication. An IV Pump would be an example of a device that is performing the administration. Both the IV Pump and the practitioner that set the rate or bolus on the pump can be listed as performers.
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| reason | 0..0 | CodeableReference(Condition | DiagnosticReport | Observation) | There are no (further) constraints on this element Element idMedicationAdministration.reasonShort description Concept, condition or observation that supports why the medication was administered DefinitionA code, Condition or observation that supports why the medication was administered. CodeableReference(Condition | DiagnosticReport | Observation) BindingA set of codes indicating the reason why the MedicationAdministration was made. ReasonMedicationGivenCodes (example) Constraints
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| request | C | 0..0 | Reference(MedicationRequest) | There are no (further) constraints on this element Element idMedicationAdministration.requestShort description Request administration performed against DefinitionThe original request, instruction or authority to perform the administration. This is a reference to the MedicationRequest where the intent is either order or instance-order. It should not reference MedicationRequests where the intent is any other value.
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| device | 0..0 | CodeableReference(Device) | There are no (further) constraints on this element Element idMedicationAdministration.deviceShort description Device used to administer DefinitionThe device that is to be used for the administration of the medication (for example, PCA Pump).
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| note | 0..0 | Annotation | There are no (further) constraints on this element Element idMedicationAdministration.noteShort description Information about the administration DefinitionExtra information about the medication administration that is not conveyed by the other attributes. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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| dosage | C | 0..1 | BackboneElement | There are no (further) constraints on this element Element idMedicationAdministration.dosageShort description Details of how medication was taken DefinitionDescribes the medication dosage information details e.g. dose, rate, site, route, etc.
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| id | 0..0 | string | There are no (further) constraints on this element Element idMedicationAdministration.dosage.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idMedicationAdministration.dosage.extensionShort description 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 managable, 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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| frequency | C | 0..1 | Extension(CodeableConcept) | Element idMedicationAdministration.dosage.extension:frequencyShort description frequency Information Alternate namesextensions, user content DefinitionExtension for capturing frequency information 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. https://fhir.synapxe.sg/StructureDefinition/ext-ot-frequency Constraints
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| modifierExtension | Σ ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idMedicationAdministration.dosage.modifierExtensionShort description 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 managable, 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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| text | C | 0..1 | string | There are no (further) constraints on this element Element idMedicationAdministration.dosage.textShort description Free text dosage instructions e.g. SIG DefinitionFree text dosage can be used for cases where the dosage administered is too complex to code. When coded dosage is present, the free text dosage may still be present for display to humans. The dosage instructions should reflect the dosage of the medication that was administered. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: mad-1 Constraints
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| site | 0..0 | CodeableConcept | There are no (further) constraints on this element Element idMedicationAdministration.dosage.siteShort description Body site administered to DefinitionA coded specification of the anatomic site where the medication first entered the body. For example, "left arm". If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension http://hl7.org/fhir/StructureDefinition/bodySite. May be a summary code, or a reference to a very precise definition of the location, or both. A coded concept describing the site location the medicine enters into or onto the body. SNOMEDCTAnatomicalStructureAdministrationSites (example) Constraints
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| route | 0..1 | CodeableConcept | Element idMedicationAdministration.dosage.routeShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject.
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| method | 0..0 | CodeableConcept | There are no (further) constraints on this element Element idMedicationAdministration.dosage.methodShort description How drug was administered DefinitionA coded value indicating the method by which the medication is intended to be or was introduced into or on the body. This attribute will most often NOT be populated. It is most commonly used for injections. For example, Slow Push, Deep IV. One of the reasons this attribute is not used often, is that the method is often pre-coordinated with the route and/or form of administration. This means the codes used in route or form may pre-coordinate the method in the route code or the form code. The implementation decision about what coding system to use for route or form code will determine how frequently the method code will be populated e.g. if route or form code pre-coordinate method code, then this attribute will not be populated often; if there is no pre-coordination then method code may be used frequently. A coded concept describing the technique by which the medicine is administered. SNOMEDCTAdministrationMethodCodes (example) Constraints
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| dose | C | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idMedicationAdministration.dosage.doseShort description Amount of medication per dose DefinitionThe amount of the medication given at one administration event. Use this value when the administration is essentially an instantaneous event such as a swallowing a tablet or giving an injection. If the administration is not instantaneous (rate is present), this can be specified to convey the total amount administered over period of time of a single administration. The cardinality or value of this element may be affected by these constraints: mad-1 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idMedicationAdministration.dosage.dose.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idMedicationAdministration.dosage.dose.extensionShort description 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 managable, 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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| value | Σ | 1..1 | decimal | There are no (further) constraints on this element Element idMedicationAdministration.dosage.dose.valueShort description Numerical value (with implicit precision) DefinitionThe value of the measured amount. The value includes an implicit precision in the presentation of the value. Precision is handled implicitly in almost all cases of measurement. The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).
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| comparator | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idMedicationAdministration.dosage.dose.comparatorShort description < | <= | >= | > | ad - how to understand the value DefinitionNot allowed to be used in this context Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size If there is no comparator, then there is no modification of the value How the Quantity should be understood and represented.
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| unit | Σ | 1..1 | string | There are no (further) constraints on this element Element idMedicationAdministration.dosage.dose.unitShort description Unit representation DefinitionA human-readable form of the unit. There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size
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| system | Σ C | 1..1 | uri | There are no (further) constraints on this element Element idMedicationAdministration.dosage.dose.systemShort description System that defines coded unit form DefinitionThe identification of the system that provides the coded form of the unit. Need to know the system that defines the coded form of the unit. see http://en.wikipedia.org/wiki/Uniform_resource_identifier The cardinality or value of this element may be affected by these constraints: qty-3 Constraints
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idMedicationAdministration.dosage.dose.codeShort description Coded form of the unit DefinitionA computer processable form of the unit in some unit representation system. Need a computable form of the unit that is fixed across all forms. UCUM provides this for quantities, but SNOMED CT provides many units of interest. The preferred system is UCUM, but SNOMED CT can also be used (for customary units) or ISO 4217 for currency. The context of use may additionally require a code from a particular system. The cardinality or value of this element may be affected by these constraints: qty-3 Constraints
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| rate[x] | C | 0..0 | There are no (further) constraints on this element Element idMedicationAdministration.dosage.rate[x]Short description Dose quantity per unit of time DefinitionIdentifies the speed with which the medication was or will be introduced into the patient. Typically, the rate for an infusion e.g. 100 ml per 1 hour or 100 ml/hr. May also be expressed as a rate per unit of time, e.g. 500 ml per 2 hours. Other examples: 200 mcg/min or 200 mcg/1 minute; 1 liter/8 hours. If the rate changes over time, and you want to capture this in MedicationAdministration, then each change should be captured as a distinct MedicationAdministration, with a specific MedicationAdministration.dosage.rate, and the date time when the rate change occurred. Typically, the MedicationAdministration.dosage.rate element is not used to convey an average rate. The cardinality or value of this element may be affected by these constraints: mad-1 Constraints
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| eventHistory | C | 0..0 | Reference(Provenance) | There are no (further) constraints on this element Element idMedicationAdministration.eventHistoryShort description A list of events of interest in the lifecycle DefinitionA summary of the events of interest that have occurred, such as when the administration was verified. This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject.
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| DiagnosticReport | C | DiagnosticReport | There are no (further) constraints on this element Element idDiagnosticReportShort description A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Alternate namesReport, Test, Result, Results, Labs, Laboratory DefinitionThe findings and interpretation of diagnostic tests performed on patients, groups of patients, products, substances, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. The report also includes non-clinical context such as batch analysis and stability reporting of products and substances. This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idDiagnosticReport.idShort description 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. Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idDiagnosticReport.metaShort description 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 idDiagnosticReport.implicitRulesShort description 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 its 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 idDiagnosticReport.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). IETF language tag for a human language
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| text | C | 0..1 | Narrative | There are no (further) constraints on this element Element idDiagnosticReport.textShort description 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 a 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. The cardinality or value of this element may be affected by these constraints: dom-6 Constraints
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| contained | C | 0..* | Resource | There are no (further) constraints on this element Element idDiagnosticReport.containedShort description 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, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning. 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. The cardinality or value of this element may be affected by these constraints: dom-2, dom-4, dom-3, dom-5 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.extensionShort description 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 managable, 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 ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.modifierExtensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| identifier | Σ C | 1..1 | Identifier | Element idDiagnosticReport.identifierShort description An identifier intended for computation Alternate namesReportID, Filler ID, Placer ID DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.
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| id | 0..0 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idDiagnosticReport.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idDiagnosticReport.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/sequence-noExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idDiagnosticReport.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idDiagnosticReport.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| basedOn | C | 0..0 | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | There are no (further) constraints on this element Element idDiagnosticReport.basedOnShort description What was requested Alternate namesRequest DefinitionDetails concerning a service requested. This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon. Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Constraints
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| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.statusShort description registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown DefinitionThe status of the diagnostic report. Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The status of the diagnostic report. DiagnosticReportStatus (required) Constraints
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| category | Σ | 0..1 | CodeableConcept | Element idDiagnosticReport.categoryShort description Concept - reference to a terminology or just text Alternate namesDepartment, Sub-department, Service, Discipline DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. HL7 V2 table 0074 DiagnosticServiceSectionCodes (example) Constraints
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| code | Σ | 1..1 | CodeableConceptBinding | Element idDiagnosticReport.codeShort description Concept - reference to a terminology or just text Alternate namesType DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. LOINC Codes for Diagnostic Reports LOINCDiagnosticReportCodes (preferred) Constraints
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| subject | Σ C | 0..0 | Reference(BiologicallyDerivedProduct | Device | Group | Location | Medication | Organization | Patient | Practitioner | Substance) | There are no (further) constraints on this element Element idDiagnosticReport.subjectShort description The subject of the report - usually, but not always, the patient Alternate namesPatient DefinitionThe subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources. SHALL know the subject context. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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(BiologicallyDerivedProduct | Device | Group | Location | Medication | Organization | Patient | Practitioner | Substance) Constraints
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| encounter | Σ C | 0..0 | Reference(Encounter) | There are no (further) constraints on this element Element idDiagnosticReport.encounterShort description Health care event when test ordered Alternate namesContext DefinitionThe healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. Links the request to the Encounter context. This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).
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| effective[x] | Σ | 0..1 | There are no (further) constraints on this element Element idDiagnosticReport.effective[x]Short description Clinically relevant time/time-period for report Alternate namesObservation time, Effective Time, Occurrence DefinitionThe time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. Need to know where in the patient history to file/present this report. If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.
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| effectiveDateTime | dateTime | There are no (further) constraints on this element Data type | ||
| effectivePeriod | Period | There are no (further) constraints on this element Data type | ||
| issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.issuedShort description DateTime this version was made Alternate namesDate published, Date Issued, Date Verified DefinitionThe date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. Clinicians need to be able to check the date that the report was released. May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.
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| performer | Σ C | 0..1 | Reference(Practitioner) | Element idDiagnosticReport.performerShort description Responsible Diagnostic Service Alternate namesLaboratory, Service, Practitioner, Department, Company, Authorized by, Director DefinitionThe diagnostic service that is responsible for issuing the report. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.
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| id | 0..0 | string | There are no (further) constraints on this element Element idDiagnosticReport.performer.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idDiagnosticReport.performer.extensionShort description 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 managable, 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 | Σ C | 0..0 | string | There are no (further) constraints on this element Element idDiagnosticReport.performer.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 1..1 | uriBindingFixed Value | Element idDiagnosticReport.performer.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
PractitionerMappings
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| identifier | Σ C | 1..1 | Identifier | Element idDiagnosticReport.performer.identifierShort description An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| display | Σ C | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.performer.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| resultsInterpreter | Σ C | 0..0 | Reference(CareTeam | Organization | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element idDiagnosticReport.resultsInterpreterShort description Primary result interpreter Alternate namesAnalyzed by, Reported by DefinitionThe practitioner or organization that is responsible for the report's conclusions and interpretations. Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. Might not be the same entity that takes responsibility for the clinical report. Reference(CareTeam | Organization | Practitioner | PractitionerRole) Constraints
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| specimen | C | 0..0 | Reference(Specimen) | There are no (further) constraints on this element Element idDiagnosticReport.specimenShort description Specimens this report is based on DefinitionDetails about the specimens on which this diagnostic report is based. Need to be able to report information about the collected specimens on which the report is based. If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.
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| result | C | 0..* | Reference(Observation) | Element idDiagnosticReport.resultShort description Observations Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionObservations that are part of this diagnostic report. Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. The cardinality or value of this element may be affected by these constraints: dgr-1 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idDiagnosticReport.result.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result.extensionShort description 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 managable, 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 | Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 0..0 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ C | 0..0 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result.identifierShort description 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). This element only allows for a single identifier. In the case where additional identifers are required, use the http://hl7.org/fhir/StructureDefinition/additionalIdentifier extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| display | Σ C | 0..0 | string | There are no (further) constraints on this element Element idDiagnosticReport.result.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| note | 0..0 | Annotation | There are no (further) constraints on this element Element idDiagnosticReport.noteShort description Comments about the diagnostic report DefinitionComments about the diagnostic report. Need to be able to provide free text additional information. May include general statements about the diagnostic report, or statements about significant, unexpected or unreliable results values contained within the diagnostic report, or information about its source when relevant to its interpretation.
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| study | C | 0..0 | Reference(GenomicStudy | ImagingStudy) | There are no (further) constraints on this element Element idDiagnosticReport.studyShort description Reference to full details of an analysis associated with the diagnostic report DefinitionOne or more links to full details of any study performed during the diagnostic investigation. An ImagingStudy might comprise a set of radiologic images obtained via a procedure that are analyzed as a group. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. A GenomicStudy might comprise one or more analyses, each serving a specific purpose. These analyses may vary in method (e.g., karyotyping, CNV, or SNV detection), performer, software, devices used, or regions targeted. For laboratory-type studies like GenomeStudy, type resources will be used for tracking additional metadata and workflow aspects of complex studies. ImagingStudy and the media element are somewhat overlapping - typically, the list of image references in the media element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided. Reference(GenomicStudy | ImagingStudy) Constraints
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| supportingInfo | 0..0 | BackboneElement | There are no (further) constraints on this element Element idDiagnosticReport.supportingInfoShort description Additional information supporting the diagnostic report DefinitionThis backbone element contains supporting information that was used in the creation of the report not included in the results already included in the report.
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| media | Σ | 0..0 | BackboneElement | There are no (further) constraints on this element Element idDiagnosticReport.mediaShort description Key images or data associated with this report Alternate namesDICOM, Slides, Scans DefinitionA list of key images or data associated with this report. The images or data are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). Many diagnostic services include images or data in the report as part of their service.
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| composition | C | 0..0 | Reference(Composition) | There are no (further) constraints on this element Element idDiagnosticReport.compositionShort description Reference to a Composition resource for the DiagnosticReport structure DefinitionReference to a Composition resource instance that provides structure for organizing the contents of the DiagnosticReport. The Composition provides structure to the content of the DiagnosticReport (and only contains contents referenced in the DiagnosticReport) - e.g., to order the sections of an anatomic pathology structured report. The cardinality or value of this element may be affected by these constraints: dgr-1 Constraints
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| conclusion | 0..1 | markdown | There are no (further) constraints on this element Element idDiagnosticReport.conclusionShort description Clinical conclusion (interpretation) of test results Alternate namesReport DefinitionConcise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. Need to be able to provide a conclusion that is not lost among the basic result data. Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/
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| conclusionCode | 0..* | CodeableConcept | Element idDiagnosticReport.conclusionCodeShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. SNOMED CT Clinical Findings SNOMEDCTClinicalFindings (example) Constraints
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| presentedForm | C | 0..* | Attachment | Element idDiagnosticReport.presentedFormShort description Content in a format defined elsewhere DefinitionFor referring to data content defined in other formats. Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. When providing a summary view (for example with Observation.value[x]) Attachment should be represented with a brief display text such as "Signed Procedure Consent".
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| Procedure | C | Procedure | There are no (further) constraints on this element Element idProcedureShort description An action that is being or was performed on an individual or entity DefinitionAn action that is or was performed on or for a patient, practitioner, device, organization, or location. For example, this can be a physical intervention on a patient like an operation, or less invasive like long term services, counseling, or hypnotherapy. This can be a quality or safety inspection for a location, organization, or device. This can be an accreditation procedure on a practitioner for licensing.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idProcedure.idShort description 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. Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idProcedure.metaShort description 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 idProcedure.implicitRulesShort description 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 its 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 idProcedure.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). IETF language tag for a human language
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| text | C | 0..1 | Narrative | There are no (further) constraints on this element Element idProcedure.textShort description 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 a 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. The cardinality or value of this element may be affected by these constraints: dom-6 Constraints
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| contained | C | 0..* | Device, MedicationAdministration | Element idProcedure.containedShort description 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, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning. 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. Device, MedicationAdministration ConditionsThe cardinality or value of this element may be affected by these constraints: dom-2, dom-4, dom-3, dom-5 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.extensionShort description 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 managable, 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 ?! C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.modifierExtensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| identifier | Σ C | 1..1 | Identifier | Element idProcedure.identifierShort description An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idProcedure.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idProcedure.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/sequence-noExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idProcedure.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idProcedure.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idProcedure.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| instantiatesCanonical | Σ | 0..0 | canonical(ActivityDefinition | Measure | OperationDefinition | PlanDefinition | Questionnaire) | There are no (further) constraints on this element Element idProcedure.instantiatesCanonicalShort description Instantiates FHIR protocol or definition DefinitionThe URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. canonical(ActivityDefinition | Measure | OperationDefinition | PlanDefinition | Questionnaire) Constraints
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| instantiatesUri | Σ | 0..0 | uri | There are no (further) constraints on this element Element idProcedure.instantiatesUriShort description Instantiates external protocol or definition DefinitionThe URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
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| basedOn | Σ C | 0..1 | Reference(ServiceRequest) | Element idProcedure.basedOnShort description A request for this procedure Alternate namesfulfills DefinitionA reference to a resource that contains details of the request for this procedure. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| partOf | Σ C | 0..0 | Reference(MedicationAdministration | Observation | Procedure) | There are no (further) constraints on this element Element idProcedure.partOfShort description Part of referenced event Alternate namescontainer DefinitionA larger event of which this particular procedure is a component or step. The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration). Reference(MedicationAdministration | Observation | Procedure) Constraints
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| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.statusShort description preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown DefinitionA code specifying the state of the procedure. Generally, this will be the in-progress or completed state. The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. A code specifying the state of the procedure.
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| statusReason | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.statusReasonShort description Reason for current status Alternate namesSuspended Reason, Cancelled Reason DefinitionCaptures the reason for the current state of the procedure. This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here. A code that identifies the reason a procedure was not performed. ProcedureNotPerformedReasonSNOMEDCT (example) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.statusReason.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.statusReason.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 0..0 | Coding | There are no (further) constraints on this element Element idProcedure.statusReason.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| text | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.statusReason.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| category | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.categoryShort description Classification of the procedure DefinitionA code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code that classifies a procedure for searching, sorting and display purposes. ProcedureCategoryCodesSNOMEDCT (example) Constraints
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| code | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.codeShort description Identification of the procedure Alternate namestype DefinitionThe specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code to identify a specific procedure . ProcedureCodesSNOMEDCT (example) Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..1 | Coding | There are no (further) constraints on this element Element idProcedure.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idProcedure.code.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idProcedure.code.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.code.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| subject | Σ C | 1..1 | Reference(Patient) | Element idProcedure.subjectShort description A reference from one resource to another Alternate namespatient DefinitionA reference from one resource to another. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.subject.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.subject.extensionShort description 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 managable, 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 | Σ C | 0..0 | string | There are no (further) constraints on this element Element idProcedure.subject.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 1..1 | uriBindingFixed Value | There are no (further) constraints on this element Element idProcedure.subject.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
PatientMappings
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| identifier | Σ C | 1..1 | Identifier | There are no (further) constraints on this element Element idProcedure.subject.identifierShort description An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.subject.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.subject.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idProcedure.subject.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.subject.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idProcedure.subject.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/nricExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idProcedure.subject.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idProcedure.subject.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idProcedure.subject.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| display | Σ C | 0..0 | string | There are no (further) constraints on this element Element idProcedure.subject.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| focus | Σ C | 0..0 | Reference(CareTeam | Group | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson | Specimen) | There are no (further) constraints on this element Element idProcedure.focusShort description Who is the target of the procedure when it is not the subject of record only DefinitionWho is the target of the procedure when it is not the subject of record only. If focus is not present, then subject is the focus. If focus is present and the subject is one of the targets of the procedure, include subject as a focus as well. If focus is present and the subject is not included in focus, it implies that the procedure was only targeted on the focus. For example, when a caregiver is given education for a patient, the caregiver would be the focus and the procedure record is associated with the subject (e.g. patient). For example, use focus when recording the target of the education, training, or counseling is the parent or relative of a patient. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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(CareTeam | Group | Organization | Patient | Practitioner | PractitionerRole | RelatedPerson | Specimen) Constraints
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| encounter | Σ C | 0..1 | Reference(Encounter) | Element idProcedure.encounterShort description The Encounter during which this Procedure was created DefinitionThe Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated. This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.encounter.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.encounter.extensionShort description 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 managable, 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 | Σ C | 0..0 | string | There are no (further) constraints on this element Element idProcedure.encounter.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 0..1 | uriBindingFixed Value | Element idProcedure.encounter.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
EncounterMappings
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| identifier | Σ C | 1..1 | Identifier | There are no (further) constraints on this element Element idProcedure.encounter.identifierShort description 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). This element only allows for a single identifier. In the case where additional identifers are required, use the http://hl7.org/fhir/StructureDefinition/additionalIdentifier extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.encounter.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.encounter.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idProcedure.encounter.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.encounter.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idProcedure.encounter.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/event-idExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idProcedure.encounter.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idProcedure.encounter.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idProcedure.encounter.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| display | Σ C | 0..0 | string | There are no (further) constraints on this element Element idProcedure.encounter.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| occurrence[x] | Σ | 1..1 | There are no (further) constraints on this element Element idProcedure.occurrence[x]Short description When the procedure occurred or is occurring DefinitionEstimated or actual date, date-time, period, or age when the procedure did occur or is occurring. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured. This indicates when the procedure actually occurred or is occurring, not when it was asked/requested/ordered to occur. For the latter, look at the occurence element of the Request this Procedure is "basedOn". The status code allows differentiation of whether the timing reflects a historic event or an ongoing event. Ongoing events should not include an upper bound in the Period or Timing.bounds. Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.
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| occurrenceDateTime | dateTime | Data type | ||
| occurrencePeriod | Period | Data type | ||
| recorded | Σ | 0..0 | dateTime | There are no (further) constraints on this element Element idProcedure.recordedShort description When the procedure was first captured in the subject's record DefinitionThe date the occurrence of the procedure was first captured in the record regardless of Procedure.status (potentially after the occurrence of the event). UTC offset is allowed for dates and partial dates
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| recorder | Σ C | 0..0 | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idProcedure.recorderShort description Who recorded the procedure DefinitionIndividual who recorded the record and takes responsibility for its content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | Practitioner | PractitionerRole | RelatedPerson) Constraints
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| reported[x] | Σ | 0..0 | There are no (further) constraints on this element Element idProcedure.reported[x]Short description Reported rather than primary record Alternate namesinformer DefinitionIndicates if this record was captured as a secondary 'reported' record rather than as an original primary source-of-truth record. It may also indicate the source of the report. Reported data may have different rules on editing and may be visually distinguished from primary data.
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| performer | Σ C | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.performerShort description Who performed the procedure and what they did DefinitionIndicates who or what performed the procedure and how they were involved.
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.performer.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.performer.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.performer.modifierExtensionShort description 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 managable, 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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| function | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.performer.functionShort description Type of performance DefinitionDistinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist. Allows disambiguation of the types of involvement of different performers. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code that identifies the role of a performer of the procedure. ProcedurePerformerRoleCodes (example) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.performer.function.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.performer.function.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..1 | Coding | There are no (further) constraints on this element Element idProcedure.performer.function.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.performer.function.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.performer.function.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idProcedure.performer.function.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.function.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idProcedure.performer.function.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idProcedure.performer.function.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idProcedure.performer.function.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idProcedure.performer.function.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| actor | Σ C | 1..1 | Reference(Practitioner) | Element idProcedure.performer.actorShort description A reference from one resource to another DefinitionA reference from one resource to another. A reference to Device supports use cases, such as pacemakers. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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. The cardinality or value of this element may be affected by these constraints: prc-1 Constraints
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| onBehalfOf | C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idProcedure.performer.onBehalfOfShort description Organization the device or practitioner was acting for DefinitionThe Organization the Patient, RelatedPerson, Device, CareTeam, and HealthcareService was acting on behalf of. Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. Organization, Patient, RelatedPerson, Device, CareTeam, and HealthcareService can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. The cardinality or value of this element may be affected by these constraints: prc-1 Constraints
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| period | C | 1..1 | Period | There are no (further) constraints on this element Element idProcedure.performer.periodShort description When the performer performed the procedure DefinitionTime period during which the performer performed the procedure. 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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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.performer.period.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.performer.period.extensionShort description 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 managable, 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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| start | Σ C | 1..1 | dateTime | There are no (further) constraints on this element Element idProcedure.performer.period.startShort description Starting time with inclusive boundary DefinitionThe start of the period. The boundary is inclusive. If the low element is missing, the meaning is that the low boundary is not known. The cardinality or value of this element may be affected by these constraints: per-1 Constraints
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| end | Σ C | 1..1 | dateTime | There are no (further) constraints on this element Element idProcedure.performer.period.endShort description End time with inclusive boundary, if not ongoing DefinitionThe end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time. The end value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03. If the end of the period is missing, it means that the period is ongoing The cardinality or value of this element may be affected by these constraints: per-1 Constraints
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| location | Σ C | 0..1 | Reference(Location) | There are no (further) constraints on this element Element idProcedure.locationShort description Where the procedure happened DefinitionThe location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.location.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.location.extensionShort description 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 managable, 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 | Σ C | 0..0 | string | There are no (further) constraints on this element Element idProcedure.location.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 0..0 | uriBinding | There are no (further) constraints on this element Element idProcedure.location.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ C | 0..0 | Identifier | There are no (further) constraints on this element Element idProcedure.location.identifierShort description 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). This element only allows for a single identifier. In the case where additional identifers are required, use the http://hl7.org/fhir/StructureDefinition/additionalIdentifier extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idProcedure.location.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| reason | Σ | 0..1 | CodeableReference(Condition | DiagnosticReport | DocumentReference | Observation | Procedure) | There are no (further) constraints on this element Element idProcedure.reasonShort description The justification that the procedure was performed DefinitionThe coded reason or reference why the procedure was performed. This may be a coded entity of some type, be present as text, or be a reference to one of several resources that justify the procedure. Use Procedure.reason.concept when a code sufficiently describes the reason. Use Procedure.reason.reference when referencing a resource, which allows more information to be conveyed, such as onset date. For a single Procedure.reason, if both Procedure.reason.concept and Procedure.reason.reference are present, they are expected to be consistent with each other. CodeableReference(Condition | DiagnosticReport | DocumentReference | Observation | Procedure) BindingA code that identifies the reason a procedure is required. ProcedureReasonCodes (example) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.reason.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.reason.extensionShort description 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 managable, 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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| concept | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.reason.conceptShort description Reference to a concept (by class) DefinitionA reference to a concept - e.g. the information is identified by its general class to the degree of precision found in the terminology. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.reason.concept.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.reason.concept.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..1 | Coding | There are no (further) constraints on this element Element idProcedure.reason.concept.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.reason.concept.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.reason.concept.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idProcedure.reason.concept.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
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| version | Σ | 0..0 | string | There are no (further) constraints on this element Element idProcedure.reason.concept.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idProcedure.reason.concept.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idProcedure.reason.concept.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idProcedure.reason.concept.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idProcedure.reason.concept.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| reference | Σ C | 0..0 | Reference | There are no (further) constraints on this element Element idProcedure.reason.referenceShort description Reference to a resource (by instance) DefinitionA reference to a resource the provides exact details about the information being referenced. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.bodySiteShort description Target body sites DefinitionDetailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure. SNOMED CT Body site concepts SNOMEDCTBodyStructures (example) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.bodySite.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.bodySite.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..1 | Coding | There are no (further) constraints on this element Element idProcedure.bodySite.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.bodySite.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.bodySite.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idProcedure.bodySite.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idProcedure.bodySite.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idProcedure.bodySite.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idProcedure.bodySite.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| outcome | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.outcomeShort description The result of procedure DefinitionThe outcome of the procedure - did it resolve the reasons for the procedure being performed? If outcome contains narrative text only, it can be captured using the CodeableConcept.text. An outcome of a procedure - whether it was resolved or otherwise. ProcedureOutcomeCodesSNOMEDCT (example) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.outcome.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.outcome.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 0..0 | Coding | There are no (further) constraints on this element Element idProcedure.outcome.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| text | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.outcome.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| report | C | 0..* | Reference(DiagnosticReport) | Element idProcedure.reportShort description Any report resulting from the procedure DefinitionThis could be a histology result, pathology report, surgical report, etc. There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.report.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.report.extensionShort description 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 managable, 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 | Σ C | 0..1 | string | There are no (further) constraints on this element Element idProcedure.report.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idProcedure.report.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ C | 0..1 | Identifier | There are no (further) constraints on this element Element idProcedure.report.identifierShort description 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). This element only allows for a single identifier. In the case where additional identifers are required, use the http://hl7.org/fhir/StructureDefinition/additionalIdentifier extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| display | Σ C | 0..1 | string | There are no (further) constraints on this element Element idProcedure.report.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| complication | 0..1 | CodeableReference(Condition) | There are no (further) constraints on this element Element idProcedure.complicationShort description Complication following the procedure DefinitionAny complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues. If complications are only expressed by the narrative text, they can be captured using the CodeableReference.concept.text. Codes describing complications that resulted from a procedure. ConditionProblemDiagnosisCodes (example) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.complication.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.complication.extensionShort description 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 managable, 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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| concept | Σ | 1..1 | CodeableConceptBinding | Element idProcedure.complication.conceptShort description Reference to a concept (by class) DefinitionA reference to a concept - e.g. the information is identified by its general class to the degree of precision found in the terminology. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. ComplicationTypesValueSet (required) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.complication.concept.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.complication.concept.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 0..1 | Coding | There are no (further) constraints on this element Element idProcedure.complication.concept.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.complication.concept.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.complication.concept.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idProcedure.complication.concept.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
https://fhir.synapxe.sg/CodeSystem/complication-typesMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.concept.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idProcedure.complication.concept.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idProcedure.complication.concept.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idProcedure.complication.concept.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.concept.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| reference | Σ C | 0..0 | Reference | There are no (further) constraints on this element Element idProcedure.complication.referenceShort description Reference to a resource (by instance) DefinitionA reference to a resource the provides exact details about the information being referenced. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| followUp | 0..1 | CodeableConceptBinding | Element idProcedure.followUpShort description Instructions for follow up DefinitionIf the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Specific follow up required for a procedure e.g. removal of sutures. FollowUpTypesValueSet (required) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.followUp.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.followUp.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 0..1 | Coding | There are no (further) constraints on this element Element idProcedure.followUp.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.followUp.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.followUp.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idProcedure.followUp.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
https://fhir.synapxe.sg/CodeSystem/followup-typesMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.followUp.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idProcedure.followUp.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idProcedure.followUp.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idProcedure.followUp.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.followUp.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| note | 1..1 | Annotation | There are no (further) constraints on this element Element idProcedure.noteShort description Additional information about the procedure DefinitionAny other notes and comments about the procedure. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.note.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.note.extensionShort description 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 managable, 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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| author[x] | Σ | 0..0 | There are no (further) constraints on this element Element idProcedure.note.author[x]Short description Individual responsible for the annotation DefinitionThe individual responsible for making the annotation. Organization is used when there's no need for specific attribution as to who made the comment.
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| time | Σ | 0..0 | dateTime | There are no (further) constraints on this element Element idProcedure.note.timeShort description When the annotation was made DefinitionIndicates when this particular annotation was made. UTC offset is allowed for dates and partial dates
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| text | Σ | 1..1 | markdown | There are no (further) constraints on this element Element idProcedure.note.textShort description The annotation - text content (as markdown) DefinitionThe text of the annotation in markdown format. Systems are not required to have markdown support, so the text should be readable without markdown processing. The markdown syntax is GFM - see https://github.github.com/gfm/
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| focalDevice | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.focalDeviceShort description Manipulated, implanted, or removed device DefinitionA device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.extensionShort description 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 managable, 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 ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.modifierExtensionShort description 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 managable, 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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| action | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.focalDevice.actionShort description Kind of change to device DefinitionThe kind of change that happened to the device during the procedure. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A kind of change that happened to the device during the procedure. ProcedureDeviceActionCodes (preferred) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.action.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.action.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..1 | Coding | There are no (further) constraints on this element Element idProcedure.focalDevice.action.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.action.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.action.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idProcedure.focalDevice.action.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.action.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idProcedure.focalDevice.action.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.action.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idProcedure.focalDevice.action.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.action.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| manipulated | C | 1..1 | Reference(Device) | Element idProcedure.focalDevice.manipulatedShort description Device that was changed DefinitionThe device that was manipulated (changed) during the procedure. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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. Allowed aggregation:contained Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated.extensionShort description 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 managable, 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 | Σ C | 0..1 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ C | 0..1 | Identifier | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated.identifierShort description 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). This element only allows for a single identifier. In the case where additional identifers are required, use the http://hl7.org/fhir/StructureDefinition/additionalIdentifier extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| display | Σ C | 0..1 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| used | 0..* | CodeableReference(BiologicallyDerivedProduct | Device | Medication | Substance) | There are no (further) constraints on this element Element idProcedure.usedShort description Items used during procedure DefinitionIdentifies medications, devices and any other substance used as part of the procedure. Used for tracking contamination, etc. For devices actually implanted or removed, use Procedure.focalDevice.manipulated. CodeableReference(BiologicallyDerivedProduct | Device | Medication | Substance) BindingCodes describing items used during a procedure.
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.used.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.used.extensionShort description 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 managable, 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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| concept | Σ | 0..0 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.used.conceptShort description Reference to a concept (by class) DefinitionA reference to a concept - e.g. the information is identified by its general class to the degree of precision found in the terminology. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| reference | Σ C | 0..1 | Reference(Device | MedicationAdministration) | Element idProcedure.used.referenceShort description Reference to a resource (by instance) DefinitionA reference to a resource the provides exact details about the information being referenced. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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(Device | MedicationAdministration) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idProcedure.used.reference.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.used.reference.extensionShort description 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 managable, 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 | Σ C | 1..1 | string | There are no (further) constraints on this element Element idProcedure.used.reference.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 0..0 | uriBinding | There are no (further) constraints on this element Element idProcedure.used.reference.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ C | 0..0 | Identifier | There are no (further) constraints on this element Element idProcedure.used.reference.identifierShort description 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). This element only allows for a single identifier. In the case where additional identifers are required, use the http://hl7.org/fhir/StructureDefinition/additionalIdentifier extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| display | Σ C | 0..0 | string | There are no (further) constraints on this element Element idProcedure.used.reference.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| supportingInfo | C | 0..0 | Reference(Resource) | There are no (further) constraints on this element Element idProcedure.supportingInfoShort description Extra information relevant to the procedure DefinitionOther resources from the patient record that may be relevant to the procedure. The information from these resources was either used to create the instance or is provided to help with its interpretation. This extension should not be used if more specific inline elements or extensions are available. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| Condition | C | Condition | There are no (further) constraints on this element Element idConditionShort description Detailed information about conditions, problems or diagnoses DefinitionA clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idCondition.idShort description 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. Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idCondition.metaShort description 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 idCondition.implicitRulesShort description 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 its 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 idCondition.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). IETF language tag for a human language
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| text | C | 0..1 | Narrative | There are no (further) constraints on this element Element idCondition.textShort description 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 a 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. The cardinality or value of this element may be affected by these constraints: dom-6 Constraints
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| contained | C | 0..* | Resource | There are no (further) constraints on this element Element idCondition.containedShort description 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, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning. 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. The cardinality or value of this element may be affected by these constraints: dom-2, dom-4, dom-3, dom-5 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idCondition.extensionShort description 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 managable, 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 ?! C | 0..* | Extension | There are no (further) constraints on this element Element idCondition.modifierExtensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| identifier | Σ C | 1..1 | Identifier | Element idCondition.identifierShort description An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.
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| id | 0..0 | string | There are no (further) constraints on this element Element idCondition.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idCondition.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idCondition.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idCondition.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/sequence-noExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idCondition.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idCondition.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idCondition.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| clinicalStatus | Σ ?! C | 1..1 | CodeableConceptBinding | Element idCondition.clinicalStatusShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The clinical status of the condition or diagnosis. ConditionClinicalStatusCodes (required) ConditionsThe cardinality or value of this element may be affected by these constraints: con-3, con-2 Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idCondition.clinicalStatus.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idCondition.clinicalStatus.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idCondition.clinicalStatus.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idCondition.clinicalStatus.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idCondition.clinicalStatus.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idCondition.clinicalStatus.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
http://terminology.hl7.org/CodeSystem/condition-clinicalMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.clinicalStatus.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | codePattern | Element idCondition.clinicalStatus.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
activeMappings
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idCondition.clinicalStatus.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idCondition.clinicalStatus.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idCondition.clinicalStatus.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| verificationStatus | Σ ?! | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.verificationStatusShort description unconfirmed | provisional | differential | confirmed | refuted | entered-in-error DefinitionThe verification status to support the clinical status of the condition. The verification status pertains to the condition, itself, not to any specific condition attribute. verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. The verification status to support or decline the clinical status of the condition or diagnosis. ConditionVerificationStatus (required) Constraints
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| category | C | 0..1 | CodeableConceptBinding | Element idCondition.categoryShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A category assigned to the condition. ConditionCategoryCodes (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: con-2 Constraints
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| severity | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.severityShort description Subjective severity of condition DefinitionA subjective assessment of the severity of the condition as evaluated by the clinician. Coding of the severity with a terminology is preferred, where possible. A subjective assessment of the severity of the condition as evaluated by the clinician. ConditionDiagnosisSeverity (preferred) Constraints
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| code | Σ | 1..1 | CodeableConcept | Element idCondition.codeShort description Concept - reference to a terminology or just text Alternate namestype DefinitionA concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Identification of the condition or diagnosis. ConditionProblemDiagnosisCodes (example) Constraints
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| bodySite | Σ | 0..0 | CodeableConcept | There are no (further) constraints on this element Element idCondition.bodySiteShort description Anatomical location, if relevant DefinitionThe anatomical location where this condition manifests itself. Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodyStructure resource (e.g. to identify and track separately) then use the standard extension http://hl7.org/fhir/StructureDefinition/bodySite. May be a summary code, or a reference to a very precise definition of the location, or both. SNOMED CT Body site concepts SNOMEDCTBodyStructures (example) Constraints
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| subject | Σ C | 1..1 | Reference(Patient) | Element idCondition.subjectShort description A reference from one resource to another Alternate namespatient DefinitionA reference from one resource to another. Group is typically used for veterinary or public health use cases. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| encounter | Σ C | 0..0 | Reference(Encounter) | There are no (further) constraints on this element Element idCondition.encounterShort description The Encounter during which this Condition was created DefinitionThe Encounter during which this Condition was created or to which the creation of this record is tightly associated. This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".
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| onset[x] | Σ | 0..0 | There are no (further) constraints on this element Element idCondition.onset[x]Short description Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur. Period is generally used to convey an imprecise onset that occurred within the time period. For example, Period is not intended to convey the transition period before the chronic bronchitis or COPD condition was diagnosed, but Period can be used to convey an imprecise diagnosis date. Range is generally used to convey an imprecise age range (e.g. 4 to 6 years old). Because a Condition.code can represent multiple levels of granularity and can be modified over time, the onset and abatement dates can have ambiguity whether those dates apply to the current Condition.code or an earlier representation of that Condition.code. For example, if the Condition.code was initially documented as severe asthma, then it is ambiguous whether the onset and abatement dates apply to asthma (overall in that subject's lifetime) or when asthma transitioned to become severe.
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| abatement[x] | C | 0..0 | There are no (further) constraints on this element Element idCondition.abatement[x]Short description When in resolution/remission DefinitionThe date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Some conditions, such as chronic conditions, are never really resolved, but they can abate. There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated. Because a Condition.code can represent multiple levels of granularity and can be modified over time, the onset and abatement dates can have ambiguity whether those dates apply to the current Condition.code or an earlier representation of that Condition.code. For example, if the Condition.code was initially documented as severe asthma, then it is ambiguous whether the onset and abatement dates apply to asthma (overall in that subject's lifetime) or when asthma transitioned to become severe. The cardinality or value of this element may be affected by these constraints: con-3 Constraints
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| recordedDate | Σ | 0..0 | dateTime | There are no (further) constraints on this element Element idCondition.recordedDateShort description Date condition was first recorded DefinitionThe recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date. When onset date is unknown, recordedDate can be used to establish if the condition was present on or before a given date. If the recordedDate is known and provided by a sending system, it is preferred that the receiving system preserve that recordedDate value. If the recordedDate is not provided by the sending system, the receipt timestamp is sometimes used as the recordedDate.
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| participant | Σ | 0..0 | BackboneElement | There are no (further) constraints on this element Element idCondition.participantShort description Who or what participated in the activities related to the condition and how they were involved DefinitionIndicates who or what participated in the activities related to the condition and how they were involved.
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| stage | C | 0..0 | BackboneElement | There are no (further) constraints on this element Element idCondition.stageShort description Stage/grade, usually assessed formally DefinitionA simple summary of the stage such as "Stage 3" or "Early Onset". The determination of the stage is disease-specific, such as cancer, retinopathy of prematurity, kidney diseases, Alzheimer's, or Parkinson disease.
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| evidence | Σ | 0..0 | CodeableReference(Resource) | There are no (further) constraints on this element Element idCondition.evidenceShort description Supporting evidence for the verification status DefinitionSupporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. If the condition was confirmed, but subsequently refuted, then the evidence can be cumulative including all evidence over time. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both. For example, if the Condition.code is pneumonia, then there could be an evidence list where Condition.evidence.concept = fever (CodeableConcept), Condition.evidence.concept = cough (CodeableConcept), and Condition.evidence.reference = bronchitis (reference to Condition). SNOMEDCTClinicalFindings (example) Constraints
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| note | 0..1 | Annotation | Element idCondition.noteShort description Text node with attribution DefinitionA text note which also contains information about who made the statement and when. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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| Specimen | C | Specimen | There are no (further) constraints on this element Element idSpecimenShort description Sample for analysis DefinitionA sample to be used for analysis.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idSpecimen.idShort description 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. Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idSpecimen.metaShort description 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 idSpecimen.implicitRulesShort description 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 its 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 idSpecimen.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). IETF language tag for a human language
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| text | C | 0..1 | Narrative | There are no (further) constraints on this element Element idSpecimen.textShort description 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 a 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. The cardinality or value of this element may be affected by these constraints: dom-6 Constraints
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| contained | C | 0..* | Resource | There are no (further) constraints on this element Element idSpecimen.containedShort description 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, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning. 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. The cardinality or value of this element may be affected by these constraints: dom-2, dom-4, dom-3, dom-5 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idSpecimen.extensionShort description 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 managable, 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 ?! C | 0..* | Extension | There are no (further) constraints on this element Element idSpecimen.modifierExtensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| identifier | Σ C | 1..1 | Identifier | Element idSpecimen.identifierShort description An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.
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| id | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.identifier.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idSpecimen.identifier.extensionShort description 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 managable, 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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| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idSpecimen.identifier.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idSpecimen.identifier.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. IdentifierTypeCodes (extensible) Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idSpecimen.identifier.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, an absolute URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
https://fhir.synapxe.sg/NamingSystem/sequence-noExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ C | 1..1 | string | There are no (further) constraints on this element Element idSpecimen.identifier.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ident-1 Constraints
General 123456Mappings
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| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idSpecimen.identifier.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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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| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idSpecimen.identifier.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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| accessionIdentifier | Σ C | 0..1 | Identifier | Element idSpecimen.accessionIdentifierShort description An identifier intended for computation DefinitionAn identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers. The rules of the identifier.type determine if a check digit is part of the ID value or sent separately, such as through the checkDigit extension.
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| status | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idSpecimen.statusShort description available | unavailable | unsatisfactory | entered-in-error DefinitionThe availability of the specimen. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Codes providing the status/availability of a specimen.
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| type | Σ | 1..1 | CodeableConceptBinding | Element idSpecimen.typeShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The type of the specimen. SpecimenTypeValueSet (required) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.type.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idSpecimen.type.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idSpecimen.type.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.type.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idSpecimen.type.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idSpecimen.type.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
https://fhir.synapxe.sg/CodeSystem/specimen-typeMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idSpecimen.type.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idSpecimen.type.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idSpecimen.type.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idSpecimen.type.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.type.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| subject | Σ C | 0..0 | Reference(Patient) | Element idSpecimen.subjectShort description Where the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance, a biologically-derived product, or a device DefinitionWhere the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance, a biologically-derived product, or a device. Must know the subject context. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| receivedTime | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idSpecimen.receivedTimeShort description The time when specimen is received by the testing laboratory DefinitionTime when specimen is received by the testing laboratory for processing or testing. UTC offset is allowed for dates and partial dates
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| parent | C | 0..0 | Reference(Specimen) | There are no (further) constraints on this element Element idSpecimen.parentShort description Specimen from which this specimen originated DefinitionReference to the parent (source) specimen which is used when the specimen was either derived from or a component of another specimen. The parent specimen could be the source from which the current specimen is derived by some processing step (e.g. an aliquot or isolate or extracted nucleic acids from clinical samples) or one of many specimens that were combined to create a pooled sample.
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| request | C | 0..1 | Reference(ServiceRequest) | Element idSpecimen.requestShort description Why the specimen was collected DefinitionDetails concerning a service request that required a specimen to be collected. The request may be explicit or implied such with a ServiceRequest that requires a blood draw.
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| id | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.request.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idSpecimen.request.extensionShort description 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 managable, 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 | Σ C | 1..1 | string | There are no (further) constraints on this element Element idSpecimen.request.referenceShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2, ref-1 Constraints
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| type | Σ | 0..0 | uriBinding | There are no (further) constraints on this element Element idSpecimen.request.typeShort description Type the reference refers to (e.g. "Patient") - must be a resource in resources 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 known RESTful URL) or by resolving the target of the reference. Aa resource (or, for logical models, the URI of the logical model).
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| identifier | Σ C | 0..0 | Identifier | There are no (further) constraints on this element Element idSpecimen.request.identifierShort description 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). This element only allows for a single identifier. In the case where additional identifers are required, use the http://hl7.org/fhir/StructureDefinition/additionalIdentifier extension. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| display | Σ C | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.request.displayShort description 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. The cardinality or value of this element may be affected by these constraints: ref-2 Constraints
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| combined | Σ | 0..0 | codeBinding | There are no (further) constraints on this element Element idSpecimen.combinedShort description grouped | pooled DefinitionThis element signifies if the specimen is part of a group or pooled. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size Codes for the combined status of a specimen.
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| role | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idSpecimen.roleShort description The role the specimen serves DefinitionThe role or reason for the specimen in the testing workflow. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing specimen role.
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| feature | 0..0 | BackboneElement | There are no (further) constraints on this element Element idSpecimen.featureShort description The physical feature of a specimen DefinitionA physical feature or landmark on a specimen, highlighted for context by the collector of the specimen (e.g. surgeon), that identifies the type of feature as well as its meaning (e.g. the red ink indicating the resection margin of the right lobe of the excised prostate tissue or wire loop at radiologically suspected tumor location).
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| collection | 0..1 | BackboneElement | There are no (further) constraints on this element Element idSpecimen.collectionShort description Collection details DefinitionDetails concerning the specimen collection.
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| id | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.collection.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idSpecimen.collection.extensionShort description 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 managable, 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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| comments | C | 0..* | Extension(string) | Element idSpecimen.collection.extension:commentsShort description comments Information Alternate namesextensions, user content DefinitionExtension for capturing comments information 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. https://fhir.synapxe.sg/StructureDefinition/ext-ot-comments Constraints
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| modifierExtension | Σ ?! C | 0..0 | Extension | There are no (further) constraints on this element Element idSpecimen.collection.modifierExtensionShort description 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 managable, 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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| collector | Σ C | 0..0 | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson) | There are no (further) constraints on this element Element idSpecimen.collection.collectorShort description Who collected the specimen DefinitionPerson who collected the specimen. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | Practitioner | PractitionerRole | RelatedPerson) Constraints
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| collected[x] | Σ | 1..1 | There are no (further) constraints on this element Element idSpecimen.collection.collected[x]Short description Collection time DefinitionTime when specimen was collected from subject - the physiologically relevant time.
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| collectedDateTime | dateTime | There are no (further) constraints on this element Data type | ||
| collectedPeriod | Period | There are no (further) constraints on this element Data type | ||
| duration | Σ C | 0..0 | Duration | There are no (further) constraints on this element Element idSpecimen.collection.durationShort description How long it took to collect specimen DefinitionThe span of time over which the collection of a specimen occurred. The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
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| quantity | C | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idSpecimen.collection.quantityShort description The quantity of specimen collected DefinitionThe quantity of specimen collected; for instance the volume of a blood sample, or the physical measurement of an anatomic pathology sample. The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
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| id | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.collection.quantity.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idSpecimen.collection.quantity.extensionShort description 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 managable, 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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| value | Σ | 1..1 | decimal | There are no (further) constraints on this element Element idSpecimen.collection.quantity.valueShort description Numerical value (with implicit precision) DefinitionThe value of the measured amount. The value includes an implicit precision in the presentation of the value. Precision is handled implicitly in almost all cases of measurement. The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).
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| comparator | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idSpecimen.collection.quantity.comparatorShort description < | <= | >= | > | ad - how to understand the value DefinitionNot allowed to be used in this context Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size If there is no comparator, then there is no modification of the value How the Quantity should be understood and represented.
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| unit | Σ | 0..1 | string | There are no (further) constraints on this element Element idSpecimen.collection.quantity.unitShort description Unit representation DefinitionA human-readable form of the unit. There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size
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| system | Σ C | 0..1 | uri | There are no (further) constraints on this element Element idSpecimen.collection.quantity.systemShort description System that defines coded unit form DefinitionThe identification of the system that provides the coded form of the unit. Need to know the system that defines the coded form of the unit. see http://en.wikipedia.org/wiki/Uniform_resource_identifier The cardinality or value of this element may be affected by these constraints: qty-3 Constraints
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| code | Σ C | 0..1 | code | There are no (further) constraints on this element Element idSpecimen.collection.quantity.codeShort description Coded form of the unit DefinitionA computer processable form of the unit in some unit representation system. Need a computable form of the unit that is fixed across all forms. UCUM provides this for quantities, but SNOMED CT provides many units of interest. The preferred system is UCUM, but SNOMED CT can also be used (for customary units) or ISO 4217 for currency. The context of use may additionally require a code from a particular system. The cardinality or value of this element may be affected by these constraints: qty-3 Constraints
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| method | 0..1 | CodeableConcept | Element idSpecimen.collection.methodShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. The technique that is used to perform the procedure. FHIRSpecimenCollectionMethod (example) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.collection.method.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idSpecimen.collection.method.extensionShort description 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 managable, 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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| guidance | C | 0..1 | Extension(string) | Element idSpecimen.collection.method.extension:guidanceShort description guidance Information Alternate namesextensions, user content DefinitionExtension for capturing guidance information in QuestionnaireResponse 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. https://fhir.synapxe.sg/StructureDefinition/ext-guidance Constraints
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| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idSpecimen.collection.method.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| id | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.collection.method.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idSpecimen.collection.method.coding.extensionShort description 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 managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idSpecimen.collection.method.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
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| version | Σ | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.collection.method.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idSpecimen.collection.method.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idSpecimen.collection.method.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
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| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idSpecimen.collection.method.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.collection.method.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| device | 0..0 | CodeableReference(Device) | There are no (further) constraints on this element Element idSpecimen.collection.deviceShort description Device used to perform collection DefinitionA coded value specifying the technique that is used to perform the procedure. The device that was used to obtain the specimen (e.g. a catheter or catheter part used to draw the blood via a central line).
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| procedure | C | 0..0 | Reference(Procedure) | There are no (further) constraints on this element Element idSpecimen.collection.procedureShort description The procedure that collects the specimen DefinitionThe procedure event during which the specimen was collected (e.g. the surgery leading to the collection of a pathology sample). References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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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| bodySite | 0..1 | CodeableReference(BodyStructure) | There are no (further) constraints on this element Element idSpecimen.collection.bodySiteShort description Anatomical collection site DefinitionAnatomical location from which the specimen was collected (if subject is a patient). This is the target site. This element is not used for environmental specimens. Reasons for using BodyStructure reference include: 1.) Need to identify a specific site instance (e.g. a specific mole), 2.) a single pre-coordinated coded concept for the body site does not exist, 3.) a desire to represent bodySite using multiple attributes (e.g. modifiers). CodeableReference(BodyStructure) BindingSNOMED CT Body site concepts SNOMEDCTBodyStructures (example) Constraints
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| id | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
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| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.extensionShort description 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 managable, 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
|
| concept | Σ | 1..1 | CodeableConcept | Element idSpecimen.collection.bodySite.conceptShort description 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
|
| id | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.concept.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
| |
| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.concept.extensionShort description 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 managable, 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
|
| coding | Σ C | 1..* | Coding | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.concept.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
|
| id | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.concept.coding.idShort description 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. The cardinality or value of this element may be affected by these constraints: ele-1 Mappings
| |
| extension | C | 0..0 | Extension | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.concept.coding.extensionShort description 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 managable, 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
|
| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.concept.coding.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should be an absolute reference to some definition that establishes the system clearly and unambiguously.
|
| version | Σ | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.concept.coding.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
|
| code | Σ C | 1..1 | code | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.concept.coding.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
|
| display | Σ C | 1..1 | string | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.concept.coding.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1,048,576 (1024*1024) characters in size The cardinality or value of this element may be affected by these constraints: cod-1 Constraints
|
| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.concept.coding.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
|
| text | Σ | 0..0 | string | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.concept.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
|
| reference | Σ C | 0..1 | Reference | There are no (further) constraints on this element Element idSpecimen.collection.bodySite.referenceShort description Reference to a resource (by instance) DefinitionA reference to a resource the provides exact details about the information being referenced. References SHALL be a reference to an actual FHIR resource, and SHALL be resolvable (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.
|
| fastingStatus[x] | Σ | 0..0 | Binding | There are no (further) constraints on this element Element idSpecimen.collection.fastingStatus[x]Short description Whether or how long patient abstained from food and/or drink DefinitionAbstinence or reduction from some or all food, drink, or both, for a period of time prior to sample collection. Many diagnostic tests require fasting to facilitate accurate interpretation. Representing fasting status using this element is preferred to representing it with an observation using a 'pre-coordinated code' such as LOINC 2005-7 (Calcium [Moles/time] in 2 hour Urine --12 hours fasting), or using a component observation Codes describing the fasting status of the patient. http://terminology.hl7.org/ValueSet/v2-0916 (extensible) Constraints
|
| processing | 0..0 | BackboneElement | There are no (further) constraints on this element Element idSpecimen.processingShort description Processing and processing step details DefinitionDetails concerning processing and processing steps for the specimen.
| |
| container | 0..0 | BackboneElement | There are no (further) constraints on this element Element idSpecimen.containerShort description Direct container of specimen (tube/slide, etc.) DefinitionThe container holding the specimen. The recursive nature of containers; i.e. blood in tube in tray in rack is not addressed here.
| |
| condition | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idSpecimen.conditionShort description State of the specimen DefinitionA mode or state of being that describes the nature of the specimen. The specimen condition can be used to assess its quality or appropriateness for a specific test. Specimen condition is an observation made about the specimen. It's a point-in-time assessment. It can be used to assess its quality or appropriateness for a specific test. Codes describing the state of the specimen. http://terminology.hl7.org/ValueSet/v2-0493 (extensible) Constraints
|
| note | 0..0 | Annotation | Element idSpecimen.noteShort description Text node with attribution DefinitionA text note which also contains information about who made the statement and when. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
|
API Specification
See Composition.$submit and Composition.$retrieve for the API specification to submit and retrieve OT notes.
Terminologies
| Path | Binding Strength | Value Set (Code System) | Description |
|---|---|---|---|
| Composition.language | required | http://hl7.org/fhir/ValueSet/all-languages|5.0.0 | IETF language tag for a human language |
| Composition.status | required | http://hl7.org/fhir/ValueSet/composition-status|5.0.0 | The workflow/clinical status of the composition. |
| Composition.type | preferred | http://hl7.org/fhir/ValueSet/doc-typecodes | Type of a composition. |
| Composition.subject.type | extensible | http://hl7.org/fhir/ValueSet/resource-types | Aa resource (or, for logical models, the URI of the logical model). |
| Composition.encounter.type | extensible | http://hl7.org/fhir/ValueSet/resource-types | Aa resource (or, for logical models, the URI of the logical model). |
| Composition.attester.mode | preferred | http://hl7.org/fhir/ValueSet/composition-attestation-mode | The way in which a person authenticated a composition. |
| Composition.attester.party.type | extensible | http://hl7.org/fhir/ValueSet/resource-types | Aa resource (or, for logical models, the URI of the logical model). |
| Composition.custodian.type | extensible | http://hl7.org/fhir/ValueSet/resource-types | Aa resource (or, for logical models, the URI of the logical model). |
| Composition.relatesTo.type | required | http://hl7.org/fhir/ValueSet/related-artifact-type|5.0.0 | The type of relationship to the related artifact. |
| Composition.event.detail | example | http://terminology.hl7.org/ValueSet/v3-ActCode | This list of codes represents the main clinical acts being documented. |
| Composition.section.code | required | https://fhir.synapxe.sg/ValueSet/doc-section-code | Classification of a section of a composition/document. |
| Composition.section.code | required | https://fhir.synapxe.sg/ValueSet/doc-section-code | Classification of a section of a composition/document. |
| Composition.section.code | required | https://fhir.synapxe.sg/ValueSet/doc-section-code | Classification of a section of a composition/document. |
| Composition.section.code | required | https://fhir.synapxe.sg/ValueSet/doc-section-code | Classification of a section of a composition/document. |
| Composition.section.code | required | https://fhir.synapxe.sg/ValueSet/doc-section-code | Classification of a section of a composition/document. |
| Composition.section.code | required | https://fhir.synapxe.sg/ValueSet/doc-section-code | Classification of a section of a composition/document. |
| Composition.section.code | required | https://fhir.synapxe.sg/ValueSet/doc-section-code | Classification of a section of a composition/document. |
| Composition.section.code | required | https://fhir.synapxe.sg/ValueSet/doc-section-code | Classification of a section of a composition/document. |
XML to FHIR Mapping
| XML element | FHIR Mapping |
|---|---|
document/id |
Composition.identifier |
document/lastUpdatedTime |
Composition.date |
document/eventID |
Composition.encounter.identifier |
document/institution |
Composition.custodian.identifier |
document/accessionNumber |
Composition.identifier |
document/docType/code |
Composition.type.coding.code |
document/docType/textDescription |
Composition.type.text |
document/status/code |
Composition.status |
document/author/id |
Composition.author.identifier |
document/author/name |
Composition.author.display |
content/OTBodyItem/itemName |
Composition.section.title |
content/OTBodyItem/itemText |
Composition.section.text |
content/OTBodyItem/itemStatus |
Composition.section.status |
content/OTBodyItem/abnormalFlag |
Composition.section.extension:abnormalFlag |
procedures/procedure/name |
Composition.section.entry → Procedure.code.text |
procedures/procedure/type/code |
Composition.section.entry → Procedure.category.coding.code |
procedures/procedure/primaryOperator/id |
Composition.section.entry → Procedure.performer.actor.identifier |
procedures/procedure/primaryOperator/name |
Composition.section.entry → Procedure.performer.actor.display |
procedures/procedure/startDateTime |
Composition.section.entry → Procedure.occurenceDateTime |
procedures/procedure/reportDateTime |
Composition.section.entry → Procedure.recorded |
procedures/procedure/location/name |
Composition.section.entry → Procedure.location.display |
procedures/procedure/outcome |
Composition.section.entry → Procedure.outcome |
procedures/procedure/report/conclusion |
Composition.section.entry → Procedure.report → DiagnosticReport.conclusion |
procedures/procedure/report/category |
Composition.section.entry → Procedure.report → DiagnosticReport.category |
procedures/procedure/report/status |
Composition.section.entry → Procedure.report → DiagnosticReport.status |
procedures/procedure/report/effectiveDateTime |
Composition.section.entry → Procedure.report → DiagnosticReport.effectiveDateTime |
procedures/procedure/report/issued |
Composition.section.entry → Procedure.report → DiagnosticReport.issued |
procedures/procedure/report/performer/id |
Composition.section.entry → Procedure.report → DiagnosticReport.performer.identifier |
procedures/procedure/report/performer/name |
Composition.section.entry → Procedure.report → DiagnosticReport.performer.display |
procedures/procedure/report/result/sequenceNo |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.identifier |
procedures/procedure/report/result/code |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.code |
procedures/procedure/report/result/value |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.value[x] |
procedures/procedure/report/result/interpretation |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.interpretation |
procedures/procedure/report/result/referenceRange |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.referenceRange |
procedures/procedure/report/result/method |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.method |
procedures/procedure/report/result/comments |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.comment |
procedures/procedure/report/result/status |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.status |
procedures/procedure/report/result/effectiveDateTime |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.effectiveDateTime |
procedures/procedure/report/result/performer/id |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.performer.identifier |
procedures/procedure/report/result/performer/name |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.performer.display |
procedures/procedure/report/result/component/code |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.code |
procedures/procedure/report/result/component/value |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.value[x] |
procedures/procedure/report/result/component/unit |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.valueQuantity.unit |
procedures/procedure/report/result/component/comparator |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.valueQuantity.comparator |
procedures/procedure/report/result/component/referenceRange |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.referenceRange |
procedures/procedure/report/result/component/interpretation |
Observation.component.interpretation |
procedures/procedure/report/result/component/method |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.method |
procedures/procedure/report/result/component/comments |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.comment |
procedures/procedure/report/result/component/status/code |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.status |
procedures/procedure/report/result/component/effectiveDateTime |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.effectiveDateTime |
procedures/procedure/report/result/component/performer/id |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.performer.identifier |
procedures/procedure/report/result/component/performer/name |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.performer.display |
procedures/procedure/report/result/component/category |
Observation.component.category |
procedures/procedure/report/result/component/identifier |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.identifier |
procedures/procedure/report/result/component/valueCodeableConcept |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.valueCodeableConcept |
procedures/procedure/report/result/component/valueString |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.valueString |
procedures/procedure/report/result/component/valueQuantity/value |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.valueQuantity.value |
procedures/procedure/report/result/component/valueQuantity/unit |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.valueQuantity.unit |
procedures/procedure/report/result/component/valueQuantity/comparator |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.valueQuantity.comparator |
procedures/procedure/report/result/component/interpretation |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.component.interpretation |
content/OTBodyItem/itemName |
Composition.section.title |
content/OTBodyItem/itemText |
Composition.section.text.div |
content/OTBodyItem/itemStatus |
Composition.section.extension:status |
content/OTBodyItem/abnormalFlag |
Composition.section.extension:abnormalFlag |
content/Composition/displayMethod |
Composition.extension:displayMethod |
content/Composition/identifier |
Composition.identifier |
content/Composition/date |
Composition.date |
content/Composition/type |
Composition.type |
content/Composition/title |
Composition.title |
content/Composition/status/code |
Composition.status |
content/Composition/author/id |
Composition.author.identifier |
content/Composition/author/name |
Composition.author.display |
content/Composition/attester/time |
Composition.attester.time |
content/Composition/attester/party/id |
Composition.attester.party.identifier |
content/Composition/attester/party/name |
Composition.attester.party.display |
content/Composition/custodian/institution |
Composition.custodian.identifier |
content/Composition/encounter/identifier |
Composition.encounter.identifier |
content/Composition/accessionNumber |
Composition.identifier |
content/Composition/remarks |
Composition.notes.text |
content/Composition/section/title |
Composition.section.title |
content/Composition/section/code |
Composition.section.code |
content/Composition/section/text/status/code |
Composition.section.text.status |
content/Composition/section/text/div |
Composition.section.text.div |
content/Composition/section/entry/Procedure/sequenceNo |
Composition.section.entry → Procedure.extension:sequenceNo |
content/Composition/section/entry/Procedure/status/code |
Composition.section.entry → Procedure.status |
content/Composition/section/entry/Procedure/category |
Composition.section.entry → Procedure.category |
content/Composition/section/entry/Procedure/code |
Composition.section.entry → Procedure.code |
content/Composition/section/entry/Procedure/reasonNotPerformed |
Composition.section.entry → Procedure.statusReason |
content/Composition/section/entry/Procedure/bodySite |
Composition.section.entry → Procedure.bodySite |
content/Composition/section/entry/Procedure/reason |
Composition.section.entry → Procedure.reasonCode |
content/Composition/section/entry/Procedure/performer/id |
Composition.section.entry → Procedure.performer.actor.identifier |
content/Composition/section/entry/Procedure/performer/name |
Composition.section.entry → Procedure.performer.actor.display |
content/Composition/section/entry/Procedure/performer/role |
Composition.section.entry → Procedure.performer.function |
content/Composition/section/entry/Procedure/performed/performedDateTime |
Composition.section.entry → Procedure.performedDateTime |
content/Composition/section/entry/Procedure/performed/performedPeriod/start |
Composition.section.entry → Procedure.performedPeriod.start |
content/Composition/section/entry/Procedure/performed/performedPeriod/end |
Composition.section.entry → Procedure.performedPeriod.end |
content/Composition/section/entry/Procedure/location/name |
Composition.section.entry → Procedure.location.display |
content/Composition/section/entry/Procedure/outcome |
Composition.section.entry → Procedure.outcome |
content/Composition/section/entry/Procedure/complication |
Procedure.complication |
content/Composition/section/entry/Procedure/followUp |
Procedure.followUp |
content/Composition/section/entry/Procedure/request/ProcedureRequest/notes |
Composition.section.entry → Procedure.basedOn → ServiceRequest.note |
content/Composition/section/entry/Procedure/request/ProcedureRequest/orderedOn |
Composition.section.entry → Procedure.basedOn → ServiceRequest.authoredOn |
content/Composition/section/entry/Procedure/request/ProcedureRequest/orderer/id |
Composition.section.entry → Procedure.basedOn → ServiceRequest.requester.identifier |
content/Composition/section/entry/Procedure/request/ProcedureRequest/orderer/name |
Composition.section.entry → Procedure.basedOn → ServiceRequest.requester.display |
content/Composition/section/entry/Procedure/notes |
Composition.section.entry → Procedure.note.text |
content/Composition/section/entry/Observation/sequenceNo |
Composition.section.entry → Observation.extension:sequenceNo |
content/Composition/section/entry/Observation/status/code |
Composition.section.entry → Observation.status |
content/Composition/section/entry/Observation/code |
Composition.section.entry → Observation.code |
content/Composition/section/entry/Observation/value/valueQuantity |
Composition.section.entry → Observation.valueQuantity |
content/Composition/section/entry/Observation/value/valueCodeableConcept |
Composition.section.entry → Observation.valueCodeableConcept |
content/Composition/section/entry/Observation/value/valueString |
Composition.section.entry → Observation.valueString |
content/Composition/section/entry/Observation/interpretation |
Composition.section.entry → Observation.interpretation |
content/Composition/section/entry/Observation/comments |
Composition.section.entry → Observation.note.text |
content/Composition/section/entry/Observation/method |
Composition.section.entry → Observation.method |
content/Composition/section/entry/Observation/referenceRange/low |
Composition.section.entry → Observation.referenceRange.low.value |
content/Composition/section/entry/Observation/referenceRange/high |
Composition.section.entry → Observation.referenceRange.high.value |
content/Composition/section/entry/Observation/referenceRange/meaning/code |
Composition.section.entry → Observation.referenceRange.type |
content/Composition/section/entry/Observation/referenceRange/age/low |
Composition.section.entry → Observation.referenceRange.age.low |
content/Composition/section/entry/Observation/referenceRange/age/high |
Composition.section.entry → Observation.referenceRange.age.high |
content/Composition/section/entry/Observation/referenceRange/text |
Composition.section.entry → Observation.referenceRange.text |
content/Composition/section/entry/Practitioner/sequenceNo |
Composition.section.entry → Practitioner.extension:sequenceNo |
content/Composition/section/entry/Practitioner/id |
Composition.section.entry → Practitioner.identifier.value |
content/Composition/section/entry/Practitioner/name |
Composition.section.entry → Practitioner.name.text |
content/Composition/section/entry/Practitioner/role |
Composition.section.entry → PractitionerRole.code |
content/Composition/section/entry/Condition/sequenceNo |
Composition.section.entry → Condition.extension:sequenceNo |
content/Composition/section/entry/Condition/code |
Composition.section.entry → Condition.code |
content/Composition/section/entry/Condition/category |
Composition.section.entry → Condition.category |
content/Composition/section/entry/Condition/notes |
Composition.section.entry → Condition.note.text |
content/Composition/section/entry/Procedure/focalDevice/action |
Composition.section.entry → Procedure.focalDevice.action |
content/Composition/section/entry/Procedure/focalDevice/manipulatedDevice/identifier |
Composition.section.entry → Procedure.focalDevice.manipulatedDevice → Device.identifier.value |
content/Composition/section/entry/Procedure/focalDevice/manipulatedDevice/sequenceNo |
Composition.section.entry → Procedure.focalDevice.manipulatedDevice → Device.extension:sequenceNo |
content/Composition/section/entry/Procedure/focalDevice/manipulatedDevice/type |
Composition.section.entry → Procedure.focalDevice.manipulatedDevice → Device.type |
content/Composition/section/entry/Procedure/focalDevice/manipulatedDevice/note/text |
Composition.section.entry → Procedure.focalDevice.manipulatedDevice → Device.note.text |
content/Composition/section/entry/Procedure/focalDevice/manipulatedDevice/manufacturer |
Composition.section.entry → Procedure.focalDevice.manipulatedDevice → Device.manufacturer |
content/Composition/section/entry/Procedure/focalDevice/manipulatedDevice/model |
Composition.section.entry → Procedure.focalDevice.manipulatedDevice → Device.modelNumber |
content/Composition/section/entry/Procedure/focalDevice/manipulatedDevice/version |
Composition.section.entry → Procedure.focalDevice.manipulatedDevice → Device.version.value |
content/Composition/section/entry/Procedure/focalDevice/manipulatedDevice/manufactureDate |
Composition.section.entry → Procedure.focalDevice.manipulatedDevice → Device.manufactureDate |
content/Composition/section/entry/Procedure/focalDevice/manipulatedDevice/expiry |
Composition.section.entry → Procedure.focalDevice.manipulatedDevice → Device.expirationDate |
content/Composition/section/entry/Procedure/used/MedicationAdministration/effectiveTime/effectiveDateTime |
Composition.section.entry → MedicationAdministration.effectiveDateTime |
content/Composition/section/entry/Procedure/used/MedicationAdministration/effectiveTime/effectivePeriod/start |
Composition.section.entry → MedicationAdministration.effectivePeriod.start |
content/Composition/section/entry/Procedure/used/MedicationAdministration/effectiveTime/effectivePeriod/end |
Composition.section.entry → MedicationAdministration.effectivePeriod.end |
content/Composition/section/entry/Procedure/used/MedicationAdministration/sequenceNo |
Composition.section.entry → MedicationAdministration.extension:sequenceNo |
content/Composition/section/entry/Procedure/used/MedicationAdministration/medication/code |
Composition.section.entry → MedicationAdministration.medicationCodeableConcept.coding.code |
content/Composition/section/entry/Procedure/used/MedicationAdministration/dosage/text |
Composition.section.entry → MedicationAdministration.dosage.text |
content/Composition/section/entry/Procedure/used/MedicationAdministration/dosage/route |
Composition.section.entry → MedicationAdministration.dosage.route |
content/Composition/section/entry/Procedure/used/MedicationAdministration/dosage/quantity/value |
Composition.section.entry → MedicationAdministration.dosage.dose.value |
content/Composition/section/entry/Procedure/used/MedicationAdministration/dosage/quantity/unit/code |
Composition.section.entry → MedicationAdministration.dosage.dose.code |
content/Composition/section/entry/Procedure/used/MedicationAdministration/dosage/frequency |
Composition.section.entry → MedicationAdministration.dosage.rate |
content/Composition/section/entry/Procedure/used/Device/identifier |
Composition.section.entry → Procedure.used → Device.identifier.value |
content/Composition/section/entry/Procedure/used/Device/sequenceNo |
Composition.section.entry → Procedure.used → Device.extension:sequenceNo |
content/Composition/section/entry/Procedure/used/Device/type |
Composition.section.entry → Procedure.used → Device.type |
content/Composition/section/entry/Procedure/used/Device/note/text |
Composition.section.entry → Procedure.used → Device.note.text |
content/Composition/section/entry/Procedure/used/Device/manufacturer |
Composition.section.entry → Procedure.used → Device.manufacturer |
content/Composition/section/entry/Procedure/used/Device/model |
Composition.section.entry → Procedure.used → Device.modelNumber |
content/Composition/section/entry/Procedure/used/Device/version |
Composition.section.entry → Procedure.used → Device.version.value |
content/Composition/section/entry/Procedure/used/Device/manufactureDate |
Composition.section.entry → Procedure.used → Device.manufactureDate |
content/Composition/section/entry/Procedure/used/Device/expiry |
Composition.section.entry → Procedure.used → Device.expirationDate |
content/Composition/section/entry/Procedure/report/sequenceNo |
Composition.section.entry → Procedure.report → DiagnosticReport.extension:sequenceNo |
content/Composition/section/entry/Procedure/report/status |
Composition.section.entry → Procedure.report → DiagnosticReport.status |
content/Composition/section/entry/Procedure/report/category |
Composition.section.entry → Procedure.report → DiagnosticReport.category |
content/Composition/section/entry/Procedure/report/code |
Composition.section.entry → Procedure.report → DiagnosticReport.code |
content/Composition/section/entry/Procedure/report/effective/effectiveDateTime |
Composition.section.entry → Procedure.report → DiagnosticReport.effectiveDateTime |
content/Composition/section/entry/Procedure/report/effective/effectivePeriod/start |
Composition.section.entry → Procedure.report → DiagnosticReport.effectivePeriod.start |
content/Composition/section/entry/Procedure/report/effective/effectivePeriod/end |
Composition.section.entry → Procedure.report → DiagnosticReport.effectivePeriod.end |
content/Composition/section/entry/Procedure/report/issued |
Composition.section.entry → Procedure.report → DiagnosticReport.issued |
content/Composition/section/entry/Procedure/report/performer/id |
Composition.section.entry → Procedure.report → DiagnosticReport.performer.identifier |
content/Composition/section/entry/Procedure/report/performer/name |
Composition.section.entry → Procedure.report → DiagnosticReport.performer.display |
content/Composition/section/entry/Procedure/report/performer/role |
Composition.section.entry → Procedure.report → DiagnosticReport.performer.extension:role |
content/Composition/section/entry/Procedure/report/result/sequenceNo |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.extension:sequenceNo |
content/Composition/section/entry/Procedure/report/result/status/code |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.status |
content/Composition/section/entry/Procedure/report/result/code |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.code |
content/Composition/section/entry/Procedure/report/result/value/valueQuantity/value |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.valueQuantity.value |
content/Composition/section/entry/Procedure/report/result/value/valueQuantity/comparator |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.valueQuantity.comparator |
content/Composition/section/entry/Procedure/report/result/value/valueQuantity/unit/code |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.valueQuantity.code |
content/Composition/section/entry/Procedure/report/result/value/valueCodeableConcept |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.valueCodeableConcept |
content/Composition/section/entry/Procedure/report/result/value/valueString |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.valueString |
content/Composition/section/entry/Procedure/report/result/interpretation |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.interpretation |
content/Composition/section/entry/Procedure/report/result/comments |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.note.text |
content/Composition/section/entry/Procedure/report/result/method |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.method |
content/Composition/section/entry/Procedure/report/result/referenceRange/low |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.referenceRange.low.value |
content/Composition/section/entry/Procedure/report/result/referenceRange/high |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.referenceRange.high.value |
content/Composition/section/entry/Procedure/report/result/referenceRange/meaning |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.referenceRange.type |
content/Composition/section/entry/Procedure/report/result/referenceRange/age/low |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.referenceRange.appliesTo.extension:age.low |
content/Composition/section/entry/Procedure/report/result/referenceRange/age/high |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.referenceRange.appliesTo.extension:age.high |
content/Composition/section/entry/Procedure/report/result/referenceRange/text |
Composition.section.entry → Procedure.report → DiagnosticReport.result → Observation.referenceRange.text |
content/Composition/section/entry/Procedure/report/conclusion |
Composition.section.entry → Procedure.report → DiagnosticReport.conclusion |
content/Composition/section/entry/Procedure/report/codedDiagnosis |
Composition.section.entry → Procedure.report → DiagnosticReport.conclusionCode |
content/Composition/section/entry/Procedure/report/presentedForm/contentType |
Composition.section.entry → Procedure.report → DiagnosticReport.presentedForm.contentType |
content/Composition/section/entry/Procedure/report/presentedForm/language |
Composition.section.entry → Procedure.report → DiagnosticReport.presentedForm.language |
content/Composition/section/entry/Procedure/report/presentedForm/data |
Composition.section.entry → Procedure.report → DiagnosticReport.presentedForm.data |
content/Composition/section/entry/Procedure/report/presentedForm/size |
Composition.section.entry → Procedure.report → DiagnosticReport.presentedForm.size |
content/Composition/section/entry/Procedure/report/presentedForm/title |
Composition.section.entry → Procedure.report → DiagnosticReport.presentedForm.title |
content/Composition/section/entry/Procedure/report/presentedForm/comments |
Composition.section.entry → Procedure.report → DiagnosticReport.presentedForm.extension:comments |
content/Composition/section/entry/MedicationAdministration/effectiveTime/effectiveDateTime |
Composition.section.entry → Procedure.partOf → MedicationAdministration.effectiveDateTime |
content/Composition/section/entry/MedicationAdministration/effectiveTime/effectivePeriod/start |
Composition.section.entry → Procedure.partOf → MedicationAdministration.effectivePeriod.start |
content/Composition/section/entry/MedicationAdministration/effectiveTime/effectivePeriod/end |
Composition.section.entry → Procedure.partOf → MedicationAdministration.effectivePeriod.end |
fileAttachment/sequenceNo |
Composition.relatesTo.extension:sequenceNo |
fileAttachment/attachmentCategory |
Composition.relatesTo.type |
fileAttachment/contentType |
Composition.relatesTo.document.contentType |
fileAttachment/language |
Composition.relatesTo.document.language |
fileAttachment/file |
Composition.relatesTo.document.data |
fileAttachment/size |
Composition.relatesTo.document.size |
fileAttachment/title |
Composition.relatesTo.document.title |
fileAttachment/comments |
Composition.relatesTo.display |