Name Flags Card. Type Description & Constraints doco
. . Extension
. . . extension ..1 Assertion date and time of the statement
. . . . url "assertionDate"
. . . . valueDateTime dateTime
. . . extension ..1 Information source
. . . . url "informationSource"
. . . . valueReference Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
. . . extension ..1 Statement note
. . . . url "statementNote"
. . . . valueString string
. . . url "http://hl7.org/fhir/ips/StructureDefinition/statement-uv-ips"
. . . value[x] .. 0

doco Documentation for this format
<status value="draft" /> <date value="2018-03-07T09:32:09+01:00" /> <description value="An extension defined for the International Patient Summary to record the details about a statement, if not already covered by the base resource. A statement can refer to different resources as Immunizations; Procedures;..." /> <jurisdiction> <coding> <system value="http://unstats.un.org/unsd/methods/m49/m49.htm" /> <code value="001" /> <display value="World" /> </coding> </jurisdiction> <purpose value="Record information about a statement" /> <fhirVersion value="3.0.1" /> <kind value="complex-type" /> <abstract value="false" /> <contextType value="resource" /> <context value="Immunization" /> <context value="Procedure" /> <type value="Extension" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/Extension" /> <derivation value="constraint" /> <differential> <element id="Extension"> <path value="Extension" /> </element> <element id="Extension.extension"> <path value="Extension.extension" /> <slicing> <discriminator> <type value="value" /> <path value="url" /> </discriminator> <rules value="open" /> </slicing> </element> <element id="Extension.extension:assertionDate"> <path value="Extension.extension" /> <sliceName value="assertionDate" /> <short value="Assertion date and time of the statement" /> <max value="1" /> </element> <element id="Extension.extension:assertionDate.url"> <path value="Extension.extension.url" /> <fixedUri value="assertionDate" /> </element> <element id="Extension.extension:assertionDate.valueDateTime:valueDateTime"> <path value="Extension.extension.valueDateTime" /> <sliceName value="valueDateTime" /> <type> <code value="dateTime" /> </type> </element> <element id="Extension.extension:informationSource"> <path value="Extension.extension" /> <sliceName value="informationSource" /> <short value="Information source" /> <definition value="Practitioner, patient, related person or organization acting as information source." /> <max value="1" /> </element> <element id="Extension.extension:informationSource.url"> <path value="Extension.extension.url" /> <fixedUri value="informationSource" /> </element> <element id="Extension.extension:informationSource.value[x]:valueReference"> <path value="Extension.extension.valueReference" /> <sliceName value="valueReference" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" /> </type> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/RelatedPerson" /> </type> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Practitioner" /> </type> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/PractitionerRole" /> </type> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Organization" /> </type> </element> <element id="Extension.extension:statementNote"> <path value="Extension.extension" /> <sliceName value="statementNote" /> <short value="Statement note" /> <max value="1" /> </element> <element id="Extension.extension:statementNote.url"> <path value="Extension.extension.url" /> <fixedUri value="statementNote" /> </element> <element id="Extension.extension:statementNote.value[x]:valueString"> <path value="Extension.extension.valueString" /> <sliceName value="valueString" /> <type> <code value="string" /> </type> </element> <element id="Extension.url"> <path value="Extension.url" /> <fixedUri value="http://hl7.org/fhir/ips/StructureDefinition/statement-uv-ips" /> </element> <element id="Extension.value[x]"> <path value="Extension.value[x]" /> <max value="0" /> </element> </differential> </StructureDefinition>