<status value="draft" /> <description value="A profile of Composition of PSAB derived from PSCA." /> <fhirVersion value="4.0.1" /> <kind value="resource" /> <abstract value="false" /> <type value="Composition" /> <baseDefinition value="http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/composition-ca-ps" /> <derivation value="constraint" /> <differential> <element id="Composition.id"> <path value="Composition.id" /> <mustSupport value="true" /> </element> <element id="Composition.identifier"> <path value="Composition.identifier" /> <label value="Must be UUID or equivalent identifier to ensure uniqueness across all patient summary submissions." /> <min value="1" /> </element> <element id="Composition.status"> <path value="Composition.status" /> <label value="Final = first submission of a newly curated summary Amended = modification to a previously curated and submitted summary Entered-in-error = previously submitted summary that is to be removed from the patient's record, as it was entered/submitted in error (wrong patient, unintended submission, etc.) Preliminary - NOT USED IN ALBERTA" /> </element> <element id="Composition.type.coding.system"> <path value="Composition.type.coding.system" /> <patternUri value="http://loinc.org" /> </element> <element id="Composition.type.coding.code"> <path value="Composition.type.coding.code" /> <patternCode value="60591-5" /> </element> <element id="Composition.type.text"> <path value="Composition.type.text" /> <patternString value="Alberta Patient Summary." /> </element> <element id="Composition.subject"> <path value="Composition.subject" /> <type> <code value="Reference" /> <targetProfile value="https://www.alberta.ca/fhir/psab/StructureDefinition/PatientPSAB" /> </type> </element> <element id="Composition.date"> <path value="Composition.date" /> <label value="* date" /> </element> <element id="Composition.author"> <path value="Composition.author" /> <max value="1" /> <type> <code value="Reference" /> <targetProfile value="https://www.alberta.ca/fhir/psab/StructureDefinition/PractitionerPSAB" /> <targetProfile value="https://www.alberta.ca/fhir/psab/StructureDefinition/PractitionerRolePSAB" /> <targetProfile value="https://www.alberta.ca/fhir/psab/StructureDefinition/PatientPSAB" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Device" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/RelatedPerson" /> </type> </element> <element id="Composition.title"> <path value="Composition.title" /> <patternString value="Patient Summary - AB" /> </element> <element id="Composition.confidentiality"> <path value="Composition.confidentiality" /> <min value="1" /> <patternCode value="R" /> </element> <element id="Composition.custodian.display"> <path value="Composition.custodian.display" /> <comment value="AH is responsible for the maintenance of the data (versions, archive rules, etc), not the maintenance of the content" /> <patternString value="Alberta Health" /> </element> <element id="Composition.section:sectionMedications"> <path value="Composition.section" /> <sliceName value="sectionMedications" /> </element> <element id="Composition.section:sectionMedications.title"> <path value="Composition.section.title" /> <patternString value="Medication Summary" /> </element> <element id="Composition.section:sectionMedications.code.coding.system"> <path value="Composition.section.code.coding.system" /> <patternUri value="http://loinc.org" /> </element> <element id="Composition.section:sectionMedications.code.coding.code"> <path value="Composition.section.code.coding.code" /> <patternCode value="10160-0" /> </element> <element id="Composition.section:sectionMedications.code.coding.display"> <path value="Composition.section.code.coding.display" /> <patternString value="History of Medication use Narrative" /> </element> <element id="Composition.section:sectionMedications.code.text"> <path value="Composition.section.code.text" /> <patternString value="History of medication use defines a patient's current medications and history of pertinent medications. This term may also include a patient's prescription and dispense history." /> </element> <element id="Composition.section:sectionMedications.entry:medicationStatement"> <path value="Composition.section.entry" /> <sliceName value="medicationStatement" /> <type> <code value="Reference" /> <targetProfile value="https://www.alberta.ca/fhir/psab/StructureDefinition/MedicationStatementPSAB" /> </type> <mustSupport value="true" /> </element> <element id="Composition.section:sectionMedications.emptyReason"> <path value="Composition.section.emptyReason" /> <mustSupport value="true" /> </element> <element id="Composition.section:sectionAllergies"> <path value="Composition.section" /> <sliceName value="sectionAllergies" /> </element> <element id="Composition.section:sectionAllergies.title"> <path value="Composition.section.title" /> <patternString value="Allergies and Intolerances" /> </element> <element id="Composition.section:sectionAllergies.code.coding.system"> <path value="Composition.section.code.coding.system" /> <patternUri value="http://loinc.org" /> </element> <element id="Composition.section:sectionAllergies.code.coding.code"> <path value="Composition.section.code.coding.code" /> <patternCode value="48765-2" /> </element> <element id="Composition.section:sectionAllergies.code.coding.display"> <path value="Composition.section.code.coding.display" /> <patternString value="Allergies and adverse reactions Document" /> </element> <element id="Composition.section:sectionAllergies.code.text"> <path value="Composition.section.code.text" /> <patternString value="Contains a list and description of any allergies or adverse reactions pertinent to current or past medical history. At a minimum this section should contain currently active and any relevant historical allergies and adverse reactions." /> </element> <element id="Composition.section:sectionAllergies.entry:allergyOrIntolerance"> <path value="Composition.section.entry" /> <sliceName value="allergyOrIntolerance" /> <type> <code value="Reference" /> <targetProfile value="https://www.alberta.ca/fhir/psab/StructureDefinition/AllergyIntolerancePSAB" /> </type> <mustSupport value="true" /> </element> <element id="Composition.section:sectionAllergies.emptyReason"> <path value="Composition.section.emptyReason" /> <mustSupport value="true" /> </element> <element id="Composition.section:sectionProblems"> <path value="Composition.section" /> <sliceName value="sectionProblems" /> </element> <element id="Composition.section:sectionProblems.title"> <path value="Composition.section.title" /> <patternString value="Problem List" /> </element> <element id="Composition.section:sectionProblems.code.coding.system"> <path value="Composition.section.code.coding.system" /> <patternUri value="http://loinc.org" /> </element> <element id="Composition.section:sectionProblems.code.coding.code"> <path value="Composition.section.code.coding.code" /> <patternCode value="11450-4" /> </element> <element id="Composition.section:sectionProblems.code.coding.display"> <path value="Composition.section.code.coding.display" /> <patternString value="Problem list - Reported" /> </element> <element id="Composition.section:sectionProblems.code.text"> <path value="Composition.section.code.text" /> <patternString value="Problem list - Reported" /> </element> <element id="Composition.section:sectionProblems.entry:problem"> <path value="Composition.section.entry" /> <sliceName value="problem" /> <type> <code value="Reference" /> <targetProfile value="https://www.alberta.ca/fhir/psab/StructureDefinition/ConditionPSAB" /> </type> <mustSupport value="true" /> </element> <element id="Composition.section:sectionProblems.emptyReason"> <path value="Composition.section.emptyReason" /> <mustSupport value="true" /> </element> <element id="Composition.section:sectionProceduresHx"> <path value="Composition.section" /> <sliceName value="sectionProceduresHx" /> </element> <element id="Composition.section:sectionProceduresHx.title"> <path value="Composition.section.title" /> <patternString value="History of Procedures" /> </element> <element id="Composition.section:sectionProceduresHx.code.coding.system"> <path value="Composition.section.code.coding.system" /> <patternUri value="http://loinc.org" /> </element> <element id="Composition.section:sectionProceduresHx.code.coding.code"> <path value="Composition.section.code.coding.code" /> <patternCode value="47519-4" /> </element> <element id="Composition.section:sectionProceduresHx.code.coding.display"> <path value="Composition.section.code.coding.display" /> <patternString value="History of Procedures Document" /> </element> <element id="Composition.section:sectionProceduresHx.code.text"> <path value="Composition.section.code.text" /> <patternString value="This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically and at the time the document is generated." /> </element> <element id="Composition.section:sectionProceduresHx.text"> <path value="Composition.section.text" /> <label value="may replace the resources to contain the clinical information" /> <min value="1" /> </element> <element id="Composition.section:sectionProceduresHx.emptyReason"> <path value="Composition.section.emptyReason" /> <mustSupport value="true" /> </element> <element id="Composition.section:sectionVitalSigns"> <path value="Composition.section" /> <sliceName value="sectionVitalSigns" /> </element> <element id="Composition.section:sectionVitalSigns.title"> <path value="Composition.section.title" /> <patternString value="Vital Signs" /> </element> <element id="Composition.section:sectionVitalSigns.code.coding.system"> <path value="Composition.section.code.coding.system" /> <patternUri value="http://loinc.org" /> </element> <element id="Composition.section:sectionVitalSigns.code.coding.code"> <path value="Composition.section.code.coding.code" /> <patternCode value="8716-3" /> </element> <element id="Composition.section:sectionVitalSigns.code.coding.display"> <path value="Composition.section.code.coding.display" /> <patternString value="Vital signs" /> </element> <element id="Composition.section:sectionVitalSigns.code.text"> <path value="Composition.section.code.text" /> <patternString value="The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included." /> </element> <element id="Composition.section:sectionVitalSigns.entry:BMI"> <path value="Composition.section.entry" /> <sliceName value="BMI" /> <type> <code value="Reference" /> <targetProfile value="https://www.alberta.ca/fhir/psab/StructureDefinition/ObservationBMIPSAB" /> </type> <mustSupport value="true" /> </element> <element id="Composition.section:sectionVitalSigns.entry:BodyHeight"> <path value="Composition.section.entry" /> <sliceName value="BodyHeight" /> <type> <code value="Reference" /> <targetProfile value="https://www.alberta.ca/fhir/psab/StructureDefinition/ObservationBodyHeightPSAB" /> </type> <mustSupport value="true" /> </element> <element id="Composition.section:sectionVitalSigns.entry:BodyWeight"> <path value="Composition.section.entry" /> <sliceName value="BodyWeight" /> <type> <code value="Reference" /> <targetProfile value="https://www.alberta.ca/fhir/psab/StructureDefinition/ObservationBodyWeightPSAB" /> </type> <mustSupport value="true" /> </element> <element id="Composition.section:sectionVitalSigns.entry:HeadCircum"> <path value="Composition.section.entry" /> <sliceName value="HeadCircum" /> <type> <code value="Reference" /> <targetProfile value="https://www.alberta.ca/fhir/psab/StructureDefinition/ObservationHeadCircumPSAB" /> </type> <mustSupport value="true" /> </element> <element id="Composition.section:sectionVitalSigns.emptyReason"> <path value="Composition.section.emptyReason" /> <mustSupport value="true" /> </element> <element id="Composition.section:sectionSocialHistory"> <path value="Composition.section" /> <sliceName value="sectionSocialHistory" /> </element> <element id="Composition.section:sectionSocialHistory.title"> <path value="Composition.section.title" /> <patternString value="Social History" /> </element> <element id="Composition.section:sectionSocialHistory.code.coding.system"> <path value="Composition.section.code.coding.system" /> <patternUri value="http://loinc.org" /> </element> <element id="Composition.section:sectionSocialHistory.code.coding.code"> <path value="Composition.section.code.coding.code" /> <patternCode value="29762-2" /> </element> <element id="Composition.section:sectionSocialHistory.code.coding.display"> <path value="Composition.section.code.coding.display" /> <patternString value="Social history Narrative" /> </element> <element id="Composition.section:sectionSocialHistory.code.text"> <path value="Composition.section.code.text" /> <patternString value="The Social history section contains data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation." /> </element> <element id="Composition.section:sectionSocialHistory.entry:generalSocialHistory"> <path value="Composition.section.entry" /> <sliceName value="generalSocialHistory" /> <type> <code value="Reference" /> <targetProfile value="https://www.alberta.ca/fhir/psab/StructureDefinition/ObservationSocialHistoryPSAB" /> </type> <mustSupport value="true" /> </element> <element id="Composition.section:sectionSocialHistory.emptyReason"> <path value="Composition.section.emptyReason" /> <mustSupport value="true" /> </element> <element id="Composition.section:sectionFamilyHistory"> <path value="Composition.section" /> <sliceName value="sectionFamilyHistory" /> </element> <element id="Composition.section:sectionFamilyHistory.title"> <path value="Composition.section.title" /> <patternString value="Family History" /> </element> <element id="Composition.section:sectionFamilyHistory.code.coding.system"> <path value="Composition.section.code.coding.system" /> <patternUri value="http://loinc.org" /> </element> <element id="Composition.section:sectionFamilyHistory.code.coding.code"> <path value="Composition.section.code.coding.code" /> <patternCode value="10157-6" /> </element> <element id="Composition.section:sectionFamilyHistory.code.coding.display"> <path value="Composition.section.code.coding.display" /> <patternString value="History of family member diseases Narrative" /> </element> <element id="Composition.section:sectionFamilyHistory.code.text"> <path value="Composition.section.code.text" /> <patternString value="History of family member diseases is a report of health information, including medical, genetic, environmental, and lifestyle factors, pertaining to the patient and his or her genetic relatives (living or deceased). The family history information is used to determine possible or relevant health risk factors that may have a potential impact on the patient's healthcare risk profile." /> </element> <element id="Composition.section:sectionFamilyHistory.entry:FamilyMemberHistory"> <path value="Composition.section.entry" /> <sliceName value="FamilyMemberHistory" /> <type> <code value="Reference" /> <targetProfile value="https://www.alberta.ca/fhir/psab/StructureDefinition/FamilyMemberHistoryPSAB" /> </type> </element> <element id="Composition.section:sectionFamilyHistory.emptyReason"> <path value="Composition.section.emptyReason" /> <mustSupport value="true" /> </element> </differential> </StructureDefinition>