NDHM (R4), Published and maintained by NRCeS for NHA.
This version is based on the NDHM Health Data Interchange Specifications 1.0 and updated periodically.
StructureDefinition-OPConsultRecord
This profile sets minimum expectations for the OPConsultRecord to logical package and provide a single coherent statement of meaning, establish its own context that has clinical attestation for a clinical record. 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/OPConsultRecord
This profile builds on Composition
Summary
Mandatory: 8 elements (30 nested mandatory elements)
Must-Support: 40 elements
Fixed Value: 33 elements
Structures
This structure refers to these other structures:
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Encounter
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Observation
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/AllergyIntolerance
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/FamilyMemberHistory
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/ServiceRequest
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/MedicationStatement
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Appointment
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Procedure
- 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: 371530004 | |
 display | 1..1 | string | Representation defined by the system Fixed Value: Clinical consultation report | |
| 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 |
| date | S | 1..1 | dateTime | Composition editing time |
| author | S | 1..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the composition |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| title | S | 1..1 | string | Human Readable name/title |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| party | 0..1 | Reference(RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who attested the composition | |
| custodian | 0..1 | Reference(Organization) | Organization which maintains the composition | |
 section | S | 1..* | (Slice Definition) | Composition is broken into sections Slice: Unordered, Open At End by value:code.coding.code |
   section:ChiefComplaints | 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: 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..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: 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: 371529009 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: History and physical report | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(Condition | Procedure) | 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:InvestigationAdvice | 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: 721963009 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Order document | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(ServiceRequest) | 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: 721912009 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Medication summary document | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(MedicationStatement | MedicationRequest) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:FollowUp | 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: 736271009 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Outpatient care plan | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(Appointment) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:Procedure | 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: 371525003 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Clinical procedure report | |
| 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: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: 371530004 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Clinical consultation report | |
| 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 | I | 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 | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | I | 0..* | Extension | Additional content defined by implementations |
 modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..1 | Identifier | Version-independent identifier for the Composition |
| status | ?!SΣI | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required) |
| type | SΣI | 1..1 | CodeableConcept | Kind of composition (SNOMED CT if possible) Binding: FHIRDocumentTypeCodes (preferred) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 1..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 371530004 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Clinical consultation report |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| category | ΣI | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example) |
| subject | SΣI | 1..1 | Reference(Patient) | Who and/or what the composition is about |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| encounter | SΣI | 1..1 | Reference(Encounter) | Context of the Composition |
| date | SΣI | 1..1 | dateTime | Composition editing time |
| author | SΣI | 1..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the composition |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| title | SΣI | 1..1 | string | Human Readable name/title |
| confidentiality | ΣI | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required) |
| attester | SI | 0..* | BackboneElement | Attests to accuracy of composition |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | I | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required) |
| time | I | 0..1 | dateTime | When the composition was attested |
| party | I | 0..1 | Reference(RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who attested the composition |
| custodian | ΣI | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo | I | 0..* | BackboneElement | Relationships to other compositions/documents |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | I | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required) |
 target[x] | I | 1..1 | Target of the relationship | |
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition) | |||
| event | ΣI | 0..* | BackboneElement | The clinical service(s) being documented |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | ΣI | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
| period | ΣI | 0..1 | Period | The period covered by the documentation |
| detail | ΣI | 0..* | Reference(Resource) | The event(s) being documented |
| section | SI | 1..* | (Slice Definition) | 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 | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| 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) |
| section | I | 0..* | See section | Nested Section |
| section:ChiefComplaints | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 422843007 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Chief complaint section |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(Condition) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:PhysicalExamination | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(Observation) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:Allergies | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 722446000 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Allergy record |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(AllergyIntolerance) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:MedicalHistory | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 371529009 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: History and physical report |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(Condition | Procedure) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:FamilyHistory | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 422432008 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Family history section |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(FamilyMemberHistory) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:InvestigationAdvice | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721963009 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Order document |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(ServiceRequest) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:Medications | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721912009 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Medication summary document |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(MedicationStatement | MedicationRequest) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:FollowUp | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 736271009 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Outpatient care plan |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(Appointment) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:Procedure | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 371525003 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Clinical procedure report |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(Procedure) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:DocumentReference | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 371530004 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Clinical consultation report |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(DocumentReference) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| Documentation for this format | ||||
Summary
Mandatory: 8 elements (30 nested mandatory elements)
Must-Support: 40 elements
Fixed Value: 33 elements
Structures
This structure refers to these other structures:
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Encounter
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Observation
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/AllergyIntolerance
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/FamilyMemberHistory
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/ServiceRequest
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/MedicationStatement
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Appointment
- https://nrces.in/ndhm/fhir/r4/StructureDefinition/Procedure
- 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: 371530004 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Clinical consultation report | |
| 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 |
| date | S | 1..1 | dateTime | Composition editing time |
| author | S | 1..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the composition |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| title | S | 1..1 | string | Human Readable name/title |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| party | 0..1 | Reference(RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who attested the composition | |
| custodian | 0..1 | Reference(Organization) | Organization which maintains the composition | |
| section | S | 1..* | (Slice Definition) | Composition is broken into sections Slice: Unordered, Open At End by value:code.coding.code |
| section:ChiefComplaints | 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: 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..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: 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: 371529009 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: History and physical report | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(Condition | Procedure) | 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:InvestigationAdvice | 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: 721963009 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Order document | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(ServiceRequest) | 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: 721912009 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Medication summary document | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(MedicationStatement | MedicationRequest) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:FollowUp | 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: 736271009 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Outpatient care plan | |
| text | S | 0..1 | string | Plain text representation of the concept |
| entry | S | 0..* | Reference(Appointment) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| section:Procedure | 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: 371525003 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Clinical procedure report | |
| 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: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: 371530004 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Clinical consultation report | |
| 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 | I | 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 | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..1 | Identifier | Version-independent identifier for the Composition |
| status | ?!SΣI | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required) |
| type | SΣI | 1..1 | CodeableConcept | Kind of composition (SNOMED CT if possible) Binding: FHIRDocumentTypeCodes (preferred) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | ΣI | 1..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 371530004 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Clinical consultation report |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| category | ΣI | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example) |
| subject | SΣI | 1..1 | Reference(Patient) | Who and/or what the composition is about |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| encounter | SΣI | 1..1 | Reference(Encounter) | Context of the Composition |
| date | SΣI | 1..1 | dateTime | Composition editing time |
| author | SΣI | 1..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the composition |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| title | SΣI | 1..1 | string | Human Readable name/title |
| confidentiality | ΣI | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required) |
| attester | SI | 0..* | BackboneElement | Attests to accuracy of composition |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | I | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required) |
| time | I | 0..1 | dateTime | When the composition was attested |
| party | I | 0..1 | Reference(RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who attested the composition |
| custodian | ΣI | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo | I | 0..* | BackboneElement | Relationships to other compositions/documents |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | I | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required) |
| target[x] | I | 1..1 | Target of the relationship | |
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition) | |||
| event | ΣI | 0..* | BackboneElement | The clinical service(s) being documented |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | ΣI | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
| period | ΣI | 0..1 | Period | The period covered by the documentation |
| detail | ΣI | 0..* | Reference(Resource) | The event(s) being documented |
| section | SI | 1..* | (Slice Definition) | 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 | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| 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) |
| section | I | 0..* | See section | Nested Section |
| section:ChiefComplaints | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 422843007 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Chief complaint section |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(Condition) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:PhysicalExamination | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 425044008 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Physical exam section |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(Observation) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:Allergies | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 722446000 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Allergy record |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(AllergyIntolerance) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:MedicalHistory | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 371529009 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: History and physical report |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(Condition | Procedure) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:FamilyHistory | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 422432008 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Family history section |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(FamilyMemberHistory) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:InvestigationAdvice | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721963009 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Order document |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(ServiceRequest) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:Medications | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 721912009 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Medication summary document |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(MedicationStatement | MedicationRequest) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:FollowUp | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 736271009 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Outpatient care plan |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(Appointment) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:Procedure | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 371525003 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Clinical procedure report |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(Procedure) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| section:DocumentReference | I | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 0..1 | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | ΣI | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | ΣI | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 371530004 |
| display | ΣI | 1..1 | string | Representation defined by the system Fixed Value: Clinical consultation report |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Plain text representation of the concept |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 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 | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(DocumentReference) | A reference to data that supports this section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 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 | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | See section | Nested Section |
| Documentation for this format | ||||
Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron
