This Implementation guide is published and maintained by NRCeS for NHA.
This version is based on the ABDM Health Data Interchange Specifications 1.0 and updated periodically.
StructureDefinition-DischargeSummaryRecord
This profile sets minimum expectations for the DischargeSummary document which synopsizes a patient’s admission to a hospital, healthcare provider, or other setting. It provides information for the continuation of care following discharge of a patient. It identifies the mandatory core elements, vocabularies and value sets which SHALL be present in the Composition resource when using this profile.
Examples
Formal Views of Profile Content
Description of Profiles, Differentials, and Snapshots.
The official URL for this profile is:
https://nrces.in/ndhm/fhir/r4/StructureDefinition/DischargeSummaryRecord
This profile builds on Composition
Summary
Mandatory: 7 elements (30 nested mandatory elements)
Must-Support: 38 elements
Fixed Value: 33 elements
Structures
This structure refers to these other structures:
- Patient (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient)
- Encounter (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Encounter)
- Practitioner (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner)
- PractitionerRole (https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole)
- Organization (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization)
- Condition (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition)
- Observation (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Observation)
- AllergyIntolerance (https://nrces.in/ndhm/fhir/r4/StructureDefinition/AllergyIntolerance)
- Procedure (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Procedure)
- FamilyMemberHistory (https://nrces.in/ndhm/fhir/r4/StructureDefinition/FamilyMemberHistory)
- DiagnosticReportLab (https://nrces.in/ndhm/fhir/r4/StructureDefinition/DiagnosticReportLab)
- DiagnosticReportImaging (https://nrces.in/ndhm/fhir/r4/StructureDefinition/DiagnosticReportImaging)
- MedicationRequest (https://nrces.in/ndhm/fhir/r4/StructureDefinition/MedicationRequest)
- CarePlan (https://nrces.in/ndhm/fhir/r4/StructureDefinition/CarePlan)
- DocumentReference (https://nrces.in/ndhm/fhir/r4/StructureDefinition/DocumentReference)
Slices
This structure defines the following Slices:
- The element Composition.section is sliced based on the value of value:code.coding.code (Open at End)
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  status | S | 1..1 | code | preliminary | final | amended | entered-in-error |
| type | S | 1..1 | CodeableConcept | Kind of composition (SNOMED CT if possible) |
 coding | 1..1 | Coding | Code defined by a terminology system | |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 373942005 | |
 display | 1..1 | string | Representation defined by the system Fixed Value: Discharge summary | |
| text | S | 0..1 | string | Plain text representation of the concept |
 subject | S | 1..1 | Reference(Patient) | Who and/or what the composition is about |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| encounter | S | 1..1 | Reference(Encounter) | Context of the Composition |
| author | S | 1..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the composition |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| party | 0..1 | Reference(RelatedPerson | Practitioner | PractitionerRole | Patient | Organization) | Who attested the composition | |
| custodian | 0..1 | Reference(Organization) | Organization which maintains the composition | |
 Slices for section | S | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open At End by value:code.coding.code |
   section:ChiefComplaints | 0..* | BackboneElement | Composition is broken into sections | |
  code | ||||
 coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 422843007 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Chief complaint section | |
| text | S | 0..1 | string | Plain text representation of the concept |
 entry | S | 0..* | Reference(Condition) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:PhysicalExamination | 0..* | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(Observation) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:Allergies | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 722446000 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Allergy record | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(AllergyIntolerance) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:MedicalHistory | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003642006 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Past medical history section | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(Procedure | Condition) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:FamilyHistory | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 422432008 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Family history section | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(FamilyMemberHistory) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:Investigations | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Diagnostic studies report | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(DiagnosticReportLab | DiagnosticReportImaging) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:Medications | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003606003 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Medication history section | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(MedicationRequest) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:Procedures | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003640003 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: History of past procedure section | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(Procedure) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:CarePlan | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 734163000 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Care plan | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(CarePlan) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
 section:DocumentReference | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 373942005 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Discharge summary | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(DocumentReference) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
 id | Σ | 0..1 | string | Logical id of this artifact |
 meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | 0..* | Extension | Additional content defined by implementations | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition |
| status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | SΣ | 1..1 | CodeableConcept | Kind of composition (SNOMED CT if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | Σ | 1..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 373942005 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Discharge summary |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| subject | SΣ | 1..1 | Reference(Patient) | Who and/or what the composition is about |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| encounter | SΣ | 1..1 | Reference(Encounter) | Context of the Composition |
| date | Σ | 1..1 | dateTime | Composition editing time |
| author | SΣ | 1..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the composition |
| title | Σ | 1..1 | string | Human Readable name/title |
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
| time | 0..1 | dateTime | When the composition was attested | |
| party | 0..1 | Reference(RelatedPerson | Practitioner | PractitionerRole | Patient | Organization) | Who attested the composition | |
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |
 target[x] | 1..1 | Target of the relationship | ||
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition) | |||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
| period | Σ | 0..1 | Period | The period covered by the documentation |
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
| Slices for section | SI | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open At End by value:code.coding.code |
| section:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:ChiefComplaints | I | 0..* | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 422843007 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Chief complaint section |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(Condition) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:PhysicalExamination | I | 0..* | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(Observation) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:Allergies | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 722446000 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Allergy record |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(AllergyIntolerance) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:MedicalHistory | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003642006 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Past medical history section |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(Procedure | Condition) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:FamilyHistory | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 422432008 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Family history section |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(FamilyMemberHistory) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:Investigations | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Diagnostic studies report |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(DiagnosticReportLab | DiagnosticReportImaging) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:Medications | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003606003 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Medication history section |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(MedicationRequest) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:Procedures | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003640003 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: History of past procedure section |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(Procedure) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:CarePlan | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 734163000 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Care plan |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(CarePlan) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:DocumentReference | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 373942005 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Discharge summary |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(DocumentReference) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| Documentation for this format | ||||
Summary
Mandatory: 7 elements (30 nested mandatory elements)
Must-Support: 38 elements
Fixed Value: 33 elements
Structures
This structure refers to these other structures:
- Patient (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient)
- Encounter (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Encounter)
- Practitioner (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner)
- PractitionerRole (https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole)
- Organization (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization)
- Condition (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition)
- Observation (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Observation)
- AllergyIntolerance (https://nrces.in/ndhm/fhir/r4/StructureDefinition/AllergyIntolerance)
- Procedure (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Procedure)
- FamilyMemberHistory (https://nrces.in/ndhm/fhir/r4/StructureDefinition/FamilyMemberHistory)
- DiagnosticReportLab (https://nrces.in/ndhm/fhir/r4/StructureDefinition/DiagnosticReportLab)
- DiagnosticReportImaging (https://nrces.in/ndhm/fhir/r4/StructureDefinition/DiagnosticReportImaging)
- MedicationRequest (https://nrces.in/ndhm/fhir/r4/StructureDefinition/MedicationRequest)
- CarePlan (https://nrces.in/ndhm/fhir/r4/StructureDefinition/CarePlan)
- DocumentReference (https://nrces.in/ndhm/fhir/r4/StructureDefinition/DocumentReference)
Slices
This structure defines the following Slices:
- The element Composition.section is sliced based on the value of value:code.coding.code (Open at End)
Differential View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| status | S | 1..1 | code | preliminary | final | amended | entered-in-error |
| type | S | 1..1 | CodeableConcept | Kind of composition (SNOMED CT if possible) |
| coding | 1..1 | Coding | Code defined by a terminology system | |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 373942005 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Discharge summary | |
| text | S | 0..1 | string | Plain text representation of the concept |
| subject | S | 1..1 | Reference(Patient) | Who and/or what the composition is about |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| encounter | S | 1..1 | Reference(Encounter) | Context of the Composition |
| author | S | 1..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the composition |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| party | 0..1 | Reference(RelatedPerson | Practitioner | PractitionerRole | Patient | Organization) | Who attested the composition | |
| custodian | 0..1 | Reference(Organization) | Organization which maintains the composition | |
| Slices for section | S | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open At End by value:code.coding.code |
| section:ChiefComplaints | 0..* | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 422843007 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Chief complaint section | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(Condition) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:PhysicalExamination | 0..* | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(Observation) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:Allergies | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 722446000 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Allergy record | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(AllergyIntolerance) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:MedicalHistory | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003642006 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Past medical history section | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(Procedure | Condition) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:FamilyHistory | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 422432008 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Family history section | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(FamilyMemberHistory) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:Investigations | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Diagnostic studies report | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(DiagnosticReportLab | DiagnosticReportImaging) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:Medications | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003606003 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Medication history section | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(MedicationRequest) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:Procedures | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003640003 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: History of past procedure section | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(Procedure) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:CarePlan | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 734163000 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Care plan | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(CarePlan) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:DocumentReference | 0..1 | BackboneElement | Composition is broken into sections | |
| code | ||||
| coding | S | 0..1 | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 373942005 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Discharge summary | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(DocumentReference) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition |
| status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | SΣ | 1..1 | CodeableConcept | Kind of composition (SNOMED CT if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | Σ | 1..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 373942005 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Discharge summary |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| subject | SΣ | 1..1 | Reference(Patient) | Who and/or what the composition is about |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| encounter | SΣ | 1..1 | Reference(Encounter) | Context of the Composition |
| date | Σ | 1..1 | dateTime | Composition editing time |
| author | SΣ | 1..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the composition |
| title | Σ | 1..1 | string | Human Readable name/title |
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
| time | 0..1 | dateTime | When the composition was attested | |
| party | 0..1 | Reference(RelatedPerson | Practitioner | PractitionerRole | Patient | Organization) | Who attested the composition | |
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |
| target[x] | 1..1 | Target of the relationship | ||
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition) | |||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
| period | Σ | 0..1 | Period | The period covered by the documentation |
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
| Slices for section | SI | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open At End by value:code.coding.code |
| section:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:ChiefComplaints | I | 0..* | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 422843007 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Chief complaint section |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(Condition) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:PhysicalExamination | I | 0..* | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(Observation) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:Allergies | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 722446000 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Allergy record |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(AllergyIntolerance) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:MedicalHistory | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003642006 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Past medical history section |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(Procedure | Condition) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:FamilyHistory | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 422432008 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Family history section |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(FamilyMemberHistory) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:Investigations | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721981007 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Diagnostic studies report |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(DiagnosticReportLab | DiagnosticReportImaging) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:Medications | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003606003 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Medication history section |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(MedicationRequest) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:Procedures | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1003640003 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: History of past procedure section |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(Procedure) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:CarePlan | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 734163000 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Care plan |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(CarePlan) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:DocumentReference | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| coding | SΣ | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | Σ | 0..1 | string | Version of the system - if relevant |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 373942005 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Discharge summary |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | SI | 0..* | Reference(DocumentReference) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| reference | ΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | Σ | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| Documentation for this format | ||||
Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron
