FHIR Implementation Guide for ABDM CI Build v2.0.1
banner

This Implementation guide is published and maintained by NRCeS for NHA.
This version is based on the ABDM Health Data Interchange Specifications 1.0 and updated periodically.

StructureDefinition-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:

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)
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... status S1..1codepreliminary | final | amended | entered-in-error
... type S1..1CodeableConceptKind of composition (SNOMED CT if possible)
.... coding 1..1CodingCode defined by a terminology system
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 371530004
..... display 1..1stringRepresentation defined by the system
Fixed Value: Clinical consultation report
.... text S0..1stringPlain text representation of the concept
... subject S1..1Reference(Patient)Who and/or what the composition is about
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... encounter S1..1Reference(Encounter)Context of the Composition
... date S1..1dateTimeComposition editing time
... author S1..*Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization)Who and/or what authored the composition
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... title S1..1stringHuman Readable name/title
... attester S0..*BackboneElementAttests to accuracy of composition
.... party 0..1Reference(RelatedPerson | Patient | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian 0..1Reference(Organization)Organization which maintains the composition
... Slices for section S1..*BackboneElementComposition is broken into sections
Slice: Unordered, Open At End by value:code.coding.code
.... section:ChiefComplaints 0..1BackboneElementComposition is broken into sections
..... code
...... coding S0..1CodingCode defined by a terminology system
....... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 422843007
....... display 1..1stringRepresentation defined by the system
Fixed Value: Chief complaint section
...... text S0..1stringPlain text representation of the concept
..... entry S0..*Reference(Condition)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
.... section:PhysicalExamination 0..1BackboneElementComposition is broken into sections
..... code
...... coding S0..1CodingCode defined by a terminology system
....... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 425044008
....... display 1..1stringRepresentation defined by the system
Fixed Value: Physical exam section
...... text S0..1stringPlain text representation of the concept
..... entry S0..*Reference(Observation)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
.... section:Allergies 0..1BackboneElementComposition is broken into sections
..... code
...... coding S0..1CodingCode defined by a terminology system
....... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 722446000
....... display 1..1stringRepresentation defined by the system
Fixed Value: Allergy record
...... text S0..1stringPlain text representation of the concept
..... entry S0..*Reference(AllergyIntolerance)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
.... section:MedicalHistory 0..1BackboneElementComposition is broken into sections
..... code
...... coding S0..1CodingCode defined by a terminology system
....... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 371529009
....... display 1..1stringRepresentation defined by the system
Fixed Value: History and physical report
...... text S0..1stringPlain text representation of the concept
..... entry S0..*Reference(Condition | Procedure)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
.... section:FamilyHistory 0..1BackboneElementComposition is broken into sections
..... code
...... coding S0..1CodingCode defined by a terminology system
....... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 422432008
....... display 1..1stringRepresentation defined by the system
Fixed Value: Family history section
...... text S0..1stringPlain text representation of the concept
..... entry S0..*Reference(FamilyMemberHistory)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
.... section:InvestigationAdvice 0..1BackboneElementComposition is broken into sections
..... code
...... coding S0..1CodingCode defined by a terminology system
....... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 721963009
....... display 1..1stringRepresentation defined by the system
Fixed Value: Order document
...... text S0..1stringPlain text representation of the concept
..... entry S0..*Reference(ServiceRequest)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
.... section:Medications 0..1BackboneElementComposition is broken into sections
..... code
...... coding S0..1CodingCode defined by a terminology system
....... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 721912009
....... display 1..1stringRepresentation defined by the system
Fixed Value: Medication summary document
...... text S0..1stringPlain text representation of the concept
..... entry S0..*Reference(MedicationStatement | MedicationRequest)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
.... section:FollowUp 0..1BackboneElementComposition is broken into sections
..... code
...... coding S0..1CodingCode defined by a terminology system
....... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 736271009
....... display 1..1stringRepresentation defined by the system
Fixed Value: Outpatient care plan
...... text S0..1stringPlain text representation of the concept
..... entry S0..*Reference(Appointment)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
.... section:Procedure 0..1BackboneElementComposition is broken into sections
..... code
...... coding S0..1CodingCode defined by a terminology system
....... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 371525003
....... display 1..1stringRepresentation defined by the system
Fixed Value: Clinical procedure report
...... text S0..1stringPlain text representation of the concept
..... entry S0..*Reference(Procedure)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
.... section:DocumentReference 0..1BackboneElementComposition is broken into sections
..... code
...... coding S0..1CodingCode defined by a terminology system
....... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 371530004
....... display 1..1stringRepresentation defined by the system
Fixed Value: Clinical consultation report
...... text S0..1stringPlain text representation of the concept
..... entry S0..*Reference(DocumentReference)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierVersion-independent identifier for the Composition
... status ?!SΣ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type SΣ1..1CodeableConceptKind of composition (SNOMED CT if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.

.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 371530004
..... display Σ1..1stringRepresentation defined by the system
Fixed Value: Clinical consultation report
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text SΣ0..1stringPlain text representation of the concept
... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(Patient)Who and/or what the composition is about
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... encounter SΣ1..1Reference(Encounter)Context of the Composition
... date SΣ1..1dateTimeComposition editing time
... author SΣ1..*Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization)Who and/or what authored the composition
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... title SΣ1..1stringHuman Readable name/title
... confidentiality Σ0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

... attester S0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(RelatedPerson | Patient | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(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 Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... Slices for section SI1..*BackboneElementComposition is broken into sections
Slice: Unordered, Open At End by value:code.coding.code
.... section:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification 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..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry I0..*Reference(Resource)A reference to data that supports this section
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:ChiefComplaints I0..1BackboneElementComposition is broken into sections
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ0..1CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 422843007
....... display Σ1..1stringRepresentation defined by the system
Fixed Value: Chief complaint section
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text SΣ0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SI0..*Reference(Condition)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:PhysicalExamination I0..1BackboneElementComposition is broken into sections
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ0..1CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 425044008
....... display Σ1..1stringRepresentation defined by the system
Fixed Value: Physical exam section
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text SΣ0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SI0..*Reference(Observation)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:Allergies I0..1BackboneElementComposition is broken into sections
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ0..1CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 722446000
....... display Σ1..1stringRepresentation defined by the system
Fixed Value: Allergy record
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text SΣ0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SI0..*Reference(AllergyIntolerance)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:MedicalHistory I0..1BackboneElementComposition is broken into sections
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ0..1CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 371529009
....... display Σ1..1stringRepresentation defined by the system
Fixed Value: History and physical report
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text SΣ0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SI0..*Reference(Condition | Procedure)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:FamilyHistory I0..1BackboneElementComposition is broken into sections
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ0..1CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 422432008
....... display Σ1..1stringRepresentation defined by the system
Fixed Value: Family history section
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text SΣ0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SI0..*Reference(FamilyMemberHistory)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:InvestigationAdvice I0..1BackboneElementComposition is broken into sections
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ0..1CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 721963009
....... display Σ1..1stringRepresentation defined by the system
Fixed Value: Order document
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text SΣ0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SI0..*Reference(ServiceRequest)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:Medications I0..1BackboneElementComposition is broken into sections
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ0..1CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 721912009
....... display Σ1..1stringRepresentation defined by the system
Fixed Value: Medication summary document
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text SΣ0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SI0..*Reference(MedicationStatement | MedicationRequest)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:FollowUp I0..1BackboneElementComposition is broken into sections
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ0..1CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 736271009
....... display Σ1..1stringRepresentation defined by the system
Fixed Value: Outpatient care plan
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text SΣ0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SI0..*Reference(Appointment)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:Procedure I0..1BackboneElementComposition is broken into sections
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ0..1CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 371525003
....... display Σ1..1stringRepresentation defined by the system
Fixed Value: Clinical procedure report
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text SΣ0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text I0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SI0..*Reference(Procedure)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
..... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section I0..*See section (Composition)Nested Section
.... section:DocumentReference I0..1BackboneElementComposition is broken into sections
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ0..1CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 371530004
....... display Σ1..1string