{ "resourceType": "StructureDefinition", "id": "dacdae2b-a1a9-43a2-80f9-3faf1ee547eb", "meta": { "lastUpdated": "2019-04-18T22:11:26.8261185+00:00" }, "url": "http://example.org/fhir/StructureDefinition/CompositionPS", "name": "CompositionPS", "status": "draft", "date": "2019-04-18T22:11:25.9150903+00:00", "fhirVersion": "3.0.1", "mapping": [ { "identity": "rim", "uri": "http://hl7.org/v3", "name": "RIM Mapping" }, { "identity": "cda", "uri": "http://hl7.org/v3/cda", "name": "CDA (R2)" }, { "identity": "w5", "uri": "http://hl7.org/fhir/w5", "name": "W5 Mapping" } ], "kind": "resource", "abstract": false, "type": "Composition", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Composition", "derivation": "constraint", "differential": { "element": [ { "id": "Composition.type", "path": "Composition.type", "short": "Kind of composition (\"Patient Summary\")" }, { "id": "Composition.type.coding", "path": "Composition.type.coding", "short": "Code identifying the Patient Summary", "min": 1, "max": "1" }, { "id": "Composition.type.coding.system", "path": "Composition.type.coding.system", "min": 1, "fixedUri": "http://loinc.org" }, { "id": "Composition.type.coding.code", "path": "Composition.type.coding.code", "min": 1, "fixedCode": "60591-5" }, { "id": "Composition.subject", "path": "Composition.subject", "type": [ { "code": "Reference", "targetProfile": "http://example.org/fhir/StructureDefinition/PatientPS", "aggregation": [ "referenced" ] } ] }, { "id": "Composition.author", "path": "Composition.author", "short": "Who and/or what authored the Patient Summary" }, { "id": "Composition.title", "path": "Composition.title", "short": "BC Patient Summary", "fixedString": "BC Patient Summary" }, { "id": "Composition.section", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "label": "Patient Summary", "code": [ { "system": "http://loinc.org", "code": "60591-5", "display": "Patient Summary" } ], "slicing": { "discriminator": [ { "type": "value", "path": "code.coding.code" } ], "rules": "open" }, "definition": "The root of the sections that make up the BC Patient Summary composition.", "min": 1, "mustSupport": true }, { "id": "Composition.section:MedicationsSection", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "MedicationsSection", "label": "Medications", "short": "Medications Summary Section", "definition": "The medication summary section contains a description of the patient’s medications relevant for the scope of the patient summary. It could report:\r\n• the currently active medications;\r\n• the current and past medications considered relevant by the authoring GP;\r\n• the patient prescriptions or dispensations automatically extracted by a regional or a national EHR.\r\nIn all those cases however medications are documented in the Patient Summary as medication statements. This section requires either an entry indicating the subject is known not to be on any relevant medication; either an entry indicating that no information is available about medications; or entries summarizing the subject’s relevant medications.", "min": 1, "max": "1", "mustSupport": true }, { "id": "Composition.section:MedicationsSection.title", "path": "Composition.section.title", "short": "Medication Section" }, { "id": "Composition.section:MedicationsSection.code.coding.system", "path": "Composition.section.code.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.section:MedicationsSection.code.coding.code", "path": "Composition.section.code.coding.code", "fixedCode": "10160-0" }, { "id": "Composition.section:MedicationsSection.entry", "path": "Composition.section.entry", "slicing": { "discriminator": [ { "type": "profile", "path": "reference" } ], "rules": "open" }, "min": 1, "type": [ { "code": "Reference", "targetProfile": "http://example.org/fhir/StructureDefinition/MedicationStatementPS", "aggregation": [ "referenced" ] } ] }, { "id": "Composition.section:MedicationsSection.emptyReason", "path": "Composition.section.emptyReason", "max": "0" }, { "id": "Composition.section:AllergiesSection", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "AllergiesSection", "definition": "This section documents the relevant allergies or intolerances (conditions) for a patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.", "min": 1, "max": "1", "mustSupport": true }, { "id": "Composition.section:AllergiesSection.title", "path": "Composition.section.title", "short": "Allergies and Intolerance Section" }, { "id": "Composition.section:AllergiesSection.code.coding.system", "path": "Composition.section.code.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.section:AllergiesSection.code.coding.code", "path": "Composition.section.code.coding.code", "fixedCode": "48765-2" }, { "id": "Composition.section:AllergiesSection.entry", "path": "Composition.section.entry", "slicing": { "discriminator": [ { "type": "profile", "path": "reference" } ], "rules": "open" }, "min": 1, "type": [ { "code": "Reference", "targetProfile": "http://example.org/fhir/StructureDefinition/AllergyIntolerancePS", "aggregation": [ "referenced" ] } ] }, { "id": "Composition.section:AllergiesSection.emptyReason", "path": "Composition.section.emptyReason", "max": "0" }, { "id": "Composition.section:ProblemsSection", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "ProblemsSection", "min": 1, "max": "1", "mustSupport": true }, { "id": "Composition.section:ProblemsSection.title", "path": "Composition.section.title", "min": 1 }, { "id": "Composition.section:ProblemsSection.code.coding.system", "path": "Composition.section.code.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.section:ProblemsSection.code.coding.code", "path": "Composition.section.code.coding.code", "fixedCode": "11450-4" }, { "id": "Composition.section:ProblemsSection.text", "path": "Composition.section.text", "min": 1 }, { "id": "Composition.section:ProblemsSection.entry", "path": "Composition.section.entry", "slicing": { "rules": "open" }, "min": 1, "type": [ { "code": "Reference", "targetProfile": "http://example.org/fhir/StructureDefinition/ConditionPS", "aggregation": [ "referenced" ] } ] }, { "id": "Composition.section:ProblemsSection.entry:problem", "path": "Composition.section.entry", "sliceName": "problem", "min": 1, "type": [ { "code": "Reference", "targetProfile": "http://example.org/fhir/StructureDefinition/ConditionPS" } ] }, { "id": "Composition.section:ProblemsSection.entry:problem.reference", "path": "Composition.section.entry.reference", "min": 1 }, { "id": "Composition.section:ProblemsSection.entry:problem.identifier", "path": "Composition.section.entry.identifier", "max": "0" }, { "id": "Composition.section:ProblemsSection.entry:problem.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "Composition.section.entry.display", "max": "0" }, { "id": "Composition.section:ProblemsSection.emptyReason", "path": "Composition.section.emptyReason", "max": "0" }, { "id": "Composition.section:VaccinationSection", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "VaccinationSection", "max": "1" }, { "id": "Composition.section:VaccinationSection.code.coding.system", "path": "Composition.section.code.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.section:VaccinationSection.code.coding.code", "path": "Composition.section.code.coding.code", "fixedCode": "11369-6" }, { "id": "Composition.section:VaccinationSection.entry", "path": "Composition.section.entry", "type": [ { "code": "Reference", "targetProfile": "http://example.org/fhir/StructureDefinition/ImmunizationPS" } ] }, { "id": "Composition.section:VaccinationSection.emptyReason", "path": "Composition.section.emptyReason", "max": "0" }, { "id": "Composition.section:SocialHistorySection", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "SocialHistorySection", "max": "1" }, { "id": "Composition.section:SocialHistorySection.title", "path": "Composition.section.title", "min": 1 }, { "id": "Composition.section:SocialHistorySection.code.coding.system", "path": "Composition.section.code.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.section:SocialHistorySection.code.coding.code", "path": "Composition.section.code.coding.code", "fixedCode": "29762-2" }, { "id": "Composition.section:FamiliyHistorySection", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "FamiliyHistorySection", "max": "1" }, { "id": "Composition.section:FamiliyHistorySection.title", "path": "Composition.section.title", "min": 1 }, { "id": "Composition.section:FamiliyHistorySection.code.coding.system", "path": "Composition.section.code.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.section:FamiliyHistorySection.code.coding.code", "path": "Composition.section.code.coding.code", "fixedCode": "10157-6" }, { "id": "Composition.section:FamiliyHistorySection.emptyReason", "path": "Composition.section.emptyReason", "max": "0" }, { "id": "Composition.section:AdvanceDirectivesSection", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "AdvanceDirectivesSection", "max": "1" }, { "id": "Composition.section:AdvanceDirectivesSection.code.coding.system", "path": "Composition.section.code.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.section:AdvanceDirectivesSection.code.coding.code", "path": "Composition.section.code.coding.code", "fixedCode": "42348-3" }, { "id": "Composition.section:AdvanceDirectivesSection.entry", "path": "Composition.section.entry", "type": [ { "code": "Reference", "targetProfile": "http://example.org/fhir/StructureDefinition/ConsentPS", "aggregation": [ "referenced" ] } ] }, { "id": "Composition.section:AdvanceDirectivesSection.emptyReason", "path": "Composition.section.emptyReason", "max": "0" }, { "id": "Composition.section:PregnancySection", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "PregnancySection", "max": "1" }, { "id": "Composition.section:PregnancySection.title", "path": "Composition.section.title", "min": 1 }, { "id": "Composition.section:PregnancySection.code.coding.system", "path": "Composition.section.code.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.section:PregnancySection.code.coding.code", "path": "Composition.section.code.coding.code", "fixedCode": "82810-3" }, { "id": "Composition.section:VitalSignsSection", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "VitalSignsSection", "max": "1" }, { "id": "Composition.section:VitalSignsSection.code.coding.system", "path": "Composition.section.code.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.section:VitalSignsSection.code.coding.code", "path": "Composition.section.code.coding.code", "fixedCode": "8716-3" }, { "id": "Composition.section:VitalSignsSection.entry", "path": "Composition.section.entry", "slicing": { "discriminator": [ { "type": "profile", "path": "reference" } ], "rules": "open" }, "min": 1, "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/vitalsigns" } ] }, { "id": "Composition.section:VitalSignsSection.emptyReason", "path": "Composition.section.emptyReason", "max": "0" }, { "id": "Composition.section:CompetencySection", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "CompetencySection", "max": "1" }, { "id": "Composition.section:CompetencySection.title", "path": "Composition.section.title", "min": 1 }, { "id": "Composition.section:CompetencySection.code.coding.system", "path": "Composition.section.code.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.section:CompetencySection.code.coding.code", "path": "Composition.section.code.coding.code", "fixedCode": "47420-5" }, { "id": "Composition.section:CompetencySection.text", "path": "Composition.section.text", "min": 1 }, { "id": "Composition.section:CompetencySection.entry", "path": "Composition.section.entry", "slicing": { "discriminator": [ { "type": "profile", "path": "reference" } ], "rules": "open" }, "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource", "aggregation": [ "referenced" ] } ] }, { "id": "Composition.section:CompetencySection.entry:disability", "path": "Composition.section.entry", "sliceName": "disability", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition" } ] }, { "id": "Composition.section:CompetencySection.entry:functionalAssessment", "path": "Composition.section.entry", "sliceName": "functionalAssessment", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ClinicalImpression" } ] }, { "id": "Composition.section:CompetencySection.emptyReason", "path": "Composition.section.emptyReason", "max": "0" }, { "id": "Composition.section:ProceduresHxSection", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "ProceduresHxSection", "definition": "The History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document.\r\nProcedures may refer for example to:\r\n1. Invasive Diagnostic procedure: e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)\r\n2. Therapeutic procedure: e.g. dialysis;\r\n3. Surgical procedure: e.g. appendectomy", "min": 1, "max": "1", "mustSupport": true }, { "id": "Composition.section:ProceduresHxSection.title", "path": "Composition.section.title", "min": 1 }, { "id": "Composition.section:ProceduresHxSection.code", "path": "Composition.section.code", "min": 1 }, { "id": "Composition.section:ProceduresHxSection.code.coding.system", "path": "Composition.section.code.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.section:ProceduresHxSection.code.coding.code", "path": "Composition.section.code.coding.code", "fixedCode": "47519-4" }, { "id": "Composition.section:ProceduresHxSection.entry", "path": "Composition.section.entry", "slicing": { "discriminator": [ { "type": "profile", "path": "reference" } ], "rules": "open" }, "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Procedure" } ] }, { "id": "Composition.section:ProceduresHxSection.entry:reference", "path": "Composition.section.entry", "sliceName": "reference", "short": "Literal reference, Relative, internal or absolute URL", "definition": "A 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.", "comment": "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.", "min": 1, "max": "1" }, { "id": "Composition.section:ProceduresHxSection.entry:reference.identifier", "path": "Composition.section.entry.identifier", "max": "0" }, { "id": "Composition.section:ProceduresHxSection.entry:reference.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "Composition.section.entry.display", "max": "0" }, { "id": "Composition.section:ProceduresHxSection.emptyReason", "path": "Composition.section.emptyReason", "max": "0" }, { "id": "Composition.section:MedicalDevicesSection", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "MedicalDevicesSection", "short": "Patient Summary Medical Devices Section", "definition": "History of medical device (medical equipment) use defines a patient's implanted and external medical devices and equipment that their health status depends on, as well as any pertinent equipment or device history. This term is also used to itemize any pertinent current or historical durable medical equipment (DME) used to help maintain the patient's health status. All pertinent equipment relevant to the diagnosis, care, and treatment of a patient should be included. Source: Regenstrief LOINC" }, { "id": "Composition.section:MedicalDevicesSection.title", "path": "Composition.section.title", "min": 1 }, { "id": "Composition.section:MedicalDevicesSection.code", "path": "Composition.section.code", "min": 1 }, { "id": "Composition.section:MedicalDevicesSection.code.coding.system", "path": "Composition.section.code.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.section:MedicalDevicesSection.code.coding.code", "path": "Composition.section.code.coding.code", "fixedCode": "46264-8" }, { "id": "Composition.section:MedicalDevicesSection.text", "path": "Composition.section.text", "min": 1 }, { "id": "Composition.section:MedicalDevicesSection.entry", "path": "Composition.section.entry", "slicing": { "discriminator": [ { "type": "profile", "path": "reference" } ], "description": "A reference to the actual resource from which the narrative in the section is derived.", "rules": "open" }, "min": 1 }, { "id": "Composition.section:MedicalDevicesSection.entry:deviceStatement", "path": "Composition.section.entry", "sliceName": "deviceStatement", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/DeviceUseStatement" } ] }, { "id": "Composition.section:MedicalDevicesSection.entry:deviceStatement.identifier", "path": "Composition.section.entry.identifier", "max": "0" }, { "id": "Composition.section:MedicalDevicesSection.entry:deviceStatement.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "Composition.section.entry.display", "max": "0" }, { "id": "Composition.section:MedicalDevicesSection.emptyReason", "path": "Composition.section.emptyReason", "max": "0" }, { "id": "Composition.section:PastIMedicalllnessHxSection", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString": "Section" } ], "path": "Composition.section", "sliceName": "PastIMedicalllnessHxSection" }, { "id": "Composition.section:PastIMedicalllnessHxSection.title", "path": "Composition.section.title", "min": 1 }, { "id": "Composition.section:PastIMedicalllnessHxSection.code.coding.system", "path": "Composition.section.code.coding.system", "fixedUri": "http://loinc.org" }, { "id": "Composition.section:PastIMedicalllnessHxSection.code.coding.code", "path": "Composition.section.code.coding.code", "fixedCode": "11348-0" }, { "id": "Composition.section:PastIMedicalllnessHxSection.entry", "path": "Composition.section.entry", "slicing": { "rules": "open" }, "min": 1 }, { "id": "Composition.section:PastIMedicalllnessHxSection.entry:problem", "path": "Composition.section.entry", "sliceName": "problem", "min": 1, "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition" } ] }, { "id": "Composition.section:PastIMedicalllnessHxSection.entry:problem.reference", "path": "Composition.section.entry.reference", "min": 1 }, { "id": "Composition.section:PastIMedicalllnessHxSection.entry:problem.identifier", "path": "Composition.section.entry.identifier", "max": "0" }, { "id": "Composition.section:PastIMedicalllnessHxSection.entry:problem.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "Composition.section.entry.display", "max": "0" } ] } }