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

• Bundle-OPConsultNote-example-05

• Text Summary
• Differential Table
• Snapshot Table
• Snapshot Table (Must Support)
• All

This structure is derived from Composition

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
Slices for section	S	1..*	BackboneElement	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:OtherObservations		0..1	BackboneElement	Composition is broken into sections
code
coding	S	0..*	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: 404684003
display		1..1	string	Representation defined by the system Fixed Value: Clinical finding
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: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		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Version-independent identifier for the Composition
status	?!SΣ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	SΣ	1..1	CodeableConcept	Kind of composition (SNOMED CT if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 371530004
display	Σ	1..1	string	Representation defined by the system Fixed Value: Clinical consultation report
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
category	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	1..1	Reference(Patient)	Who and/or what the composition is about
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
encounter	SΣ	1..1	Reference(Encounter)	Context of the Composition
date	SΣ	1..1	dateTime	Composition editing time
author	SΣ	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		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
title	SΣ	1..1	string	Human Readable name/title
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
attester	S	0..*	BackboneElement	Attests to accuracy of composition
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(RelatedPerson | Patient | Practitioner | PractitionerRole | Organization)	Who attested the composition
custodian	Σ	0..1	Reference(Organization)	Organization which maintains the composition
relatesTo		0..*	BackboneElement	Relationships to other compositions/documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]		1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(Composition)
event	Σ	0..*	BackboneElement	The clinical service(s) being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
Slices for section	SC	1..*	BackboneElement	Composition is broken into sections Slice: Unordered, Open At End by value:code.coding.code
section:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:ChiefComplaints	C	0..1	BackboneElement	Composition is broken into sections
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 422843007
display	Σ	1..1	string	Representation defined by the system Fixed Value: Chief complaint section
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	0..*	Reference(Condition)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:PhysicalExamination	C	0..1	BackboneElement	Composition is broken into sections
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 425044008
display	Σ	1..1	string	Representation defined by the system Fixed Value: Physical exam section
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	0..*	Reference(Observation)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:Allergies	C	0..1	BackboneElement	Composition is broken into sections
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 722446000
display	Σ	1..1	string	Representation defined by the system Fixed Value: Allergy record
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	0..*	Reference(AllergyIntolerance)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:MedicalHistory	C	0..1	BackboneElement	Composition is broken into sections
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 371529009
display	Σ	1..1	string	Representation defined by the system Fixed Value: History and physical report
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	0..*	Reference(Condition | Procedure)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:FamilyHistory	C	0..1	BackboneElement	Composition is broken into sections
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 422432008
display	Σ	1..1	string	Representation defined by the system Fixed Value: Family history section
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	0..*	Reference(FamilyMemberHistory)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:InvestigationAdvice	C	0..1	BackboneElement	Composition is broken into sections
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 721963009
display	Σ	1..1	string	Representation defined by the system Fixed Value: Order document
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	0..*	Reference(ServiceRequest)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:Medications	C	0..1	BackboneElement	Composition is broken into sections
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 721912009
display	Σ	1..1	string	Representation defined by the system Fixed Value: Medication summary document
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	0..*	Reference(MedicationStatement | MedicationRequest)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:FollowUp	C	0..1	BackboneElement	Composition is broken into sections
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 736271009
display	Σ	1..1	string	Representation defined by the system Fixed Value: Outpatient care plan
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	0..*	Reference(Appointment)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:Procedure	C	0..1	BackboneElement	Composition is broken into sections
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 371525003
display	Σ	1..1	string	Representation defined by the system Fixed Value: Clinical procedure report
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	0..*	Reference(Procedure)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:OtherObservations	C	0..1	BackboneElement	Composition is broken into sections
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 404684003
display	Σ	1..1	string	Representation defined by the system Fixed Value: Clinical finding
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	0..*	Reference(Observation)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
section:DocumentReference	C	0..1	BackboneElement	Composition is broken into sections
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 371530004
display	Σ	1..1	string	Representation defined by the system Fixed Value: Clinical consultation report
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	0..*	Reference(DocumentReference)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format