FHIR Implementation Guide for ABDM
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FHIR Implementation Guide for ABDM - Local Development build (v6.5.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: DischargeSummaryRecord

Official URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/DischargeSummaryRecord Version: 6.5.0
Draft as of 2020-08-17 Computable Name: DischargeSummaryRecord

Clinical document used to represent the discharge summary record for ABDM HDE data set.

This profile sets minimum expectations for the DischargeSummary document which synopsizes a patient’s admission to a hospital, healthcare provider, or other setting. It provides information for the continuation of care following discharge of a patient. It identifies the mandatory core elements, vocabularies and value sets which SHALL be present in the Composition resource when using this profile.

Examples

Usages:

  • This Profile is not used by any profiles in this Implementation Guide

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
.... coding Σ 1..1 Coding Code defined by a terminology system
..... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 373942005
..... display Σ 1..1 string Representation defined by the system
Fixed Value: Discharge summary
.... text SΣ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Who and/or what the composition is about
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... encounter SΣ 1..1 Reference(Encounter) Context of the Composition
... date Σ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the composition
... title Σ 1..1 string Human Readable name/title
... attester S 0..* BackboneElement Attests to accuracy of composition
.... 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.
.... party 0..1 Reference(RelatedPerson | Practitioner | PractitionerRole | Patient | Organization) Who attested the composition
... custodian Σ 0..1 Reference(Organization) Organization which maintains the composition
... Slices for section SC 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open At End by value:code.coding.code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... section:ChiefComplaints C 0..1 BackboneElement The section captures the primary reasons for the patient's admission, detailing the main symptoms or issues reported by the patient.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... 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
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(Condition) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:PhysicalExamination C 0..1 BackboneElement The section records the findings from the physical examination conducted by the healthcare provider, including vital signs and other physical assessments.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... 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
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(Observation) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Allergies C 0..1 BackboneElement The section includes details about the patient's allergies and adverse reactions to medications, foods, or other substances.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... 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
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(AllergyIntolerance) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:MedicalHistory C 0..1 BackboneElement The section records the patient's past medical history, including previous illnesses, surgeries etc.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003642006
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Past medical history section
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(Procedure | Condition) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:FamilyHistory C 0..1 BackboneElement The section records patient's relevant family medical history that may impact the patient’s health such as Diabetes etc.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... 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
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(FamilyMemberHistory) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Investigations C 0..1 BackboneElement The section includes information about diagnostic tests and investigations carried out during the patient's admission, such as lab tests, imaging studies, and other diagnostic procedures.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 721981007
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Diagnostic studies report
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(DiagnosticReportLab | DiagnosticReportImaging) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Medications C 0..1 BackboneElement The section lists the medications prescribed to the patient during their hospital stay, including dosage, frequency, and administration route.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003606003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Medication history section
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(MedicationRequest) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Procedures C 0..1 BackboneElement The section records any surgical or medical procedures performed on the patient during their admission.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003640003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: History of past procedure section
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(Procedure) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:CarePlan C 0..1 BackboneElement The section outlines the care plan developed for the patient, including treatment goals, planned interventions.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 734163000
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Care plan
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(CarePlan) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:DocumentReference C 0..1 BackboneElement The section contains references to documents related to the patient's discharge summary.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 373942005
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Discharge summary
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(DocumentReference) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
From the FHIR Standard
Composition.typepreferredFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes|4.0.1
From the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.section:ChiefComplaints.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:PhysicalExamination.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Allergies.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:MedicalHistory.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:FamilyHistory.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Investigations.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Medications.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Procedures.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:CarePlan.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:DocumentReference.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.section, Composition.section:ChiefComplaints, Composition.section:PhysicalExamination, Composition.section:Allergies, Composition.section:MedicalHistory, Composition.section:FamilyHistory, Composition.section:Investigations, Composition.section:Medications, Composition.section:Procedures, Composition.section:CarePlan, Composition.section:DocumentReferenceA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.section, Composition.section:ChiefComplaints, Composition.section:PhysicalExamination, Composition.section:Allergies, Composition.section:MedicalHistory, Composition.section:FamilyHistory, Composition.section:Investigations, Composition.section:Medications, Composition.section:Procedures, Composition.section:CarePlan, Composition.section:DocumentReferenceA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 373942005
..... display 1..1 string Representation defined by the system
Fixed Value: Discharge summary
.... text S 0..1 string Plain text representation of the concept
... subject S 1..1 Reference(Patient) Who and/or what the composition is about
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... author S 1..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the composition
... attester S 0..* BackboneElement Attests to accuracy of composition
.... party 0..1 Reference(RelatedPerson | Practitioner | PractitionerRole | Patient | Organization) Who attested the composition
... custodian 0..1 Reference(Organization) Organization which maintains the composition
... Slices for section S 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open At End by value:code.coding.code
.... section:ChiefComplaints 0..1 BackboneElement The section captures the primary reasons for the patient's admission, detailing the main symptoms or issues reported by the patient.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..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
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... 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 The section records the findings from the physical examination conducted by the healthcare provider, including vital signs and other physical assessments.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..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
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... 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 The section includes details about the patient's allergies and adverse reactions to medications, foods, or other substances.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..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
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... 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 The section records the patient's past medical history, including previous illnesses, surgeries etc.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003642006
....... display 1..1 string Representation defined by the system
Fixed Value: Past medical history section
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(Procedure | Condition) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:FamilyHistory 0..1 BackboneElement The section records patient's relevant family medical history that may impact the patient’s health such as Diabetes etc.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..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
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(FamilyMemberHistory) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Investigations 0..1 BackboneElement The section includes information about diagnostic tests and investigations carried out during the patient's admission, such as lab tests, imaging studies, and other diagnostic procedures.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 721981007
....... display 1..1 string Representation defined by the system
Fixed Value: Diagnostic studies report
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(DiagnosticReportLab | DiagnosticReportImaging) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Medications 0..1 BackboneElement The section lists the medications prescribed to the patient during their hospital stay, including dosage, frequency, and administration route.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003606003
....... display 1..1 string Representation defined by the system
Fixed Value: Medication history section
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(MedicationRequest) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Procedures 0..1 BackboneElement The section records any surgical or medical procedures performed on the patient during their admission.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003640003
....... display 1..1 string Representation defined by the system
Fixed Value: History of past procedure section
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(Procedure) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:CarePlan 0..1 BackboneElement The section outlines the care plan developed for the patient, including treatment goals, planned interventions.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 734163000
....... display 1..1 string Representation defined by the system
Fixed Value: Care plan
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(CarePlan) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:DocumentReference 0..1 BackboneElement The section contains references to documents related to the patient's discharge summary.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 373942005
....... display 1..1 string Representation defined by the system
Fixed Value: Discharge summary
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(DocumentReference) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 373942005
..... display Σ 1..1 string Representation defined by the system
Fixed Value: Discharge summary
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text SΣ 0..1 string Plain text representation of the concept
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Patient) Who and/or what the composition is about
.... id 0..1 string Unique id for inter-element referencing
.... 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 Σ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the composition
... title Σ 1..1 string Human Readable name/title
... confidentiality Σ 0..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... attester S 0..* BackboneElement Attests to accuracy of composition
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... time 0..1 dateTime When the composition was attested
.... party 0..1 Reference(RelatedPerson | Practitioner | PractitionerRole | Patient | Organization) Who attested the composition
... custodian Σ 0..1 Reference(Organization) Organization which maintains the composition
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... Slices for section SC 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open At End by value:code.coding.code
Constraints: cmp-1, cmp-2
.... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 The section captures the primary reasons for the patient's admission, detailing the main symptoms or issues reported by the patient.
Constraints: cmp-1, cmp-2
..... 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 1..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(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 The section records the findings from the physical examination conducted by the healthcare provider, including vital signs and other physical assessments.
Constraints: cmp-1, cmp-2
..... 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 1..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(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 The section includes details about the patient's allergies and adverse reactions to medications, foods, or other substances.
Constraints: cmp-1, cmp-2
..... 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 1..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(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 The section records the patient's past medical history, including previous illnesses, surgeries etc.
Constraints: cmp-1, cmp-2
..... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003642006
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Past medical history section
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 | 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:FamilyHistory C 0..1 BackboneElement The section records patient's relevant family medical history that may impact the patient’s health such as Diabetes etc.
Constraints: cmp-1, cmp-2
..... 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 1..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(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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:Investigations C 0..1 BackboneElement The section includes information about diagnostic tests and investigations carried out during the patient's admission, such as lab tests, imaging studies, and other diagnostic procedures.
Constraints: cmp-1, cmp-2
..... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 721981007
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Diagnostic studies report
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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(DiagnosticReportLab | DiagnosticReportImaging) 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 The section lists the medications prescribed to the patient during their hospital stay, including dosage, frequency, and administration route.
Constraints: cmp-1, cmp-2
..... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003606003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Medication history section
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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(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:Procedures C 0..1 BackboneElement The section records any surgical or medical procedures performed on the patient during their admission.
Constraints: cmp-1, cmp-2
..... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003640003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: History of past procedure section
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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:CarePlan C 0..1 BackboneElement The section outlines the care plan developed for the patient, including treatment goals, planned interventions.
Constraints: cmp-1, cmp-2
..... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 734163000
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Care plan
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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(CarePlan) 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 The section contains references to documents related to the patient's discharge summary.
Constraints: cmp-1, cmp-2
..... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 373942005
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Discharge summary
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages|4.0.1
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
From the FHIR Standard
Composition.typepreferredFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes|4.0.1
From the FHIR Standard
Composition.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes|4.0.1
From the FHIR Standard
Composition.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.confidentialityrequiredv3.ConfidentialityClassification
http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26
From the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
From the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:ChiefComplaints.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:ChiefComplaints.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:ChiefComplaints.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:ChiefComplaints.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:ChiefComplaints.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:PhysicalExamination.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:PhysicalExamination.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:PhysicalExamination.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:PhysicalExamination.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:PhysicalExamination.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:Allergies.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Allergies.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:Allergies.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:Allergies.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:Allergies.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:MedicalHistory.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:MedicalHistory.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:MedicalHistory.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:MedicalHistory.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:MedicalHistory.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:FamilyHistory.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:FamilyHistory.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:FamilyHistory.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:FamilyHistory.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:FamilyHistory.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:Investigations.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Investigations.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:Investigations.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:Investigations.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:Investigations.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:Medications.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Medications.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:Medications.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:Medications.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:Medications.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:Procedures.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Procedures.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:Procedures.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:Procedures.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:Procedures.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:CarePlan.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:CarePlan.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:CarePlan.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:CarePlan.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:CarePlan.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:DocumentReference.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:DocumentReference.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:DocumentReference.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:DocumentReference.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:DocumentReference.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.section, Composition.section:ChiefComplaints, Composition.section:PhysicalExamination, Composition.section:Allergies, Composition.section:MedicalHistory, Composition.section:FamilyHistory, Composition.section:Investigations, Composition.section:Medications, Composition.section:Procedures, Composition.section:CarePlan, Composition.section:DocumentReferenceA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.section, Composition.section:ChiefComplaints, Composition.section:PhysicalExamination, Composition.section:Allergies, Composition.section:MedicalHistory, Composition.section:FamilyHistory, Composition.section:Investigations, Composition.section:Medications, Composition.section:Procedures, Composition.section:CarePlan, Composition.section:DocumentReferenceA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Composition

Summary

Mandatory: 8 elements(40 nested mandatory elements)
Must-Support: 38 elements
Fixed: 33 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Composition.section (Open at End)

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
.... coding Σ 1..1 Coding Code defined by a terminology system
..... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 373942005
..... display Σ 1..1 string Representation defined by the system
Fixed Value: Discharge summary
.... text SΣ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Who and/or what the composition is about
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... encounter SΣ 1..1 Reference(Encounter) Context of the Composition
... date Σ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the composition
... title Σ 1..1 string Human Readable name/title
... attester S 0..* BackboneElement Attests to accuracy of composition
.... 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.
.... party 0..1 Reference(RelatedPerson | Practitioner | PractitionerRole | Patient | Organization) Who attested the composition
... custodian Σ 0..1 Reference(Organization) Organization which maintains the composition
... Slices for section SC 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open At End by value:code.coding.code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... section:ChiefComplaints C 0..1 BackboneElement The section captures the primary reasons for the patient's admission, detailing the main symptoms or issues reported by the patient.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... 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
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(Condition) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:PhysicalExamination C 0..1 BackboneElement The section records the findings from the physical examination conducted by the healthcare provider, including vital signs and other physical assessments.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... 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
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(Observation) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Allergies C 0..1 BackboneElement The section includes details about the patient's allergies and adverse reactions to medications, foods, or other substances.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... 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
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(AllergyIntolerance) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:MedicalHistory C 0..1 BackboneElement The section records the patient's past medical history, including previous illnesses, surgeries etc.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003642006
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Past medical history section
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(Procedure | Condition) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:FamilyHistory C 0..1 BackboneElement The section records patient's relevant family medical history that may impact the patient’s health such as Diabetes etc.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... 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
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(FamilyMemberHistory) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Investigations C 0..1 BackboneElement The section includes information about diagnostic tests and investigations carried out during the patient's admission, such as lab tests, imaging studies, and other diagnostic procedures.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 721981007
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Diagnostic studies report
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(DiagnosticReportLab | DiagnosticReportImaging) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Medications C 0..1 BackboneElement The section lists the medications prescribed to the patient during their hospital stay, including dosage, frequency, and administration route.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003606003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Medication history section
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(MedicationRequest) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Procedures C 0..1 BackboneElement The section records any surgical or medical procedures performed on the patient during their admission.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003640003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: History of past procedure section
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(Procedure) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:CarePlan C 0..1 BackboneElement The section outlines the care plan developed for the patient, including treatment goals, planned interventions.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 734163000
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Care plan
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(CarePlan) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:DocumentReference C 0..1 BackboneElement The section contains references to documents related to the patient's discharge summary.
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 0..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 373942005
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Discharge summary
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry SC 0..* Reference(DocumentReference) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
From the FHIR Standard
Composition.typepreferredFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes|4.0.1
From the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.section:ChiefComplaints.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:PhysicalExamination.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Allergies.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:MedicalHistory.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:FamilyHistory.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Investigations.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Medications.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Procedures.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:CarePlan.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:DocumentReference.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.section, Composition.section:ChiefComplaints, Composition.section:PhysicalExamination, Composition.section:Allergies, Composition.section:MedicalHistory, Composition.section:FamilyHistory, Composition.section:Investigations, Composition.section:Medications, Composition.section:Procedures, Composition.section:CarePlan, Composition.section:DocumentReferenceA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.section, Composition.section:ChiefComplaints, Composition.section:PhysicalExamination, Composition.section:Allergies, Composition.section:MedicalHistory, Composition.section:FamilyHistory, Composition.section:Investigations, Composition.section:Medications, Composition.section:Procedures, Composition.section:CarePlan, Composition.section:DocumentReferenceA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 373942005
..... display 1..1 string Representation defined by the system
Fixed Value: Discharge summary
.... text S 0..1 string Plain text representation of the concept
... subject S 1..1 Reference(Patient) Who and/or what the composition is about
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... author S 1..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the composition
... attester S 0..* BackboneElement Attests to accuracy of composition
.... party 0..1 Reference(RelatedPerson | Practitioner | PractitionerRole | Patient | Organization) Who attested the composition
... custodian 0..1 Reference(Organization) Organization which maintains the composition
... Slices for section S 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open At End by value:code.coding.code
.... section:ChiefComplaints 0..1 BackboneElement The section captures the primary reasons for the patient's admission, detailing the main symptoms or issues reported by the patient.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..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
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... 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 The section records the findings from the physical examination conducted by the healthcare provider, including vital signs and other physical assessments.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..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
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... 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 The section includes details about the patient's allergies and adverse reactions to medications, foods, or other substances.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..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
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... 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 The section records the patient's past medical history, including previous illnesses, surgeries etc.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003642006
....... display 1..1 string Representation defined by the system
Fixed Value: Past medical history section
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(Procedure | Condition) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:FamilyHistory 0..1 BackboneElement The section records patient's relevant family medical history that may impact the patient’s health such as Diabetes etc.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..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
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(FamilyMemberHistory) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Investigations 0..1 BackboneElement The section includes information about diagnostic tests and investigations carried out during the patient's admission, such as lab tests, imaging studies, and other diagnostic procedures.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 721981007
....... display 1..1 string Representation defined by the system
Fixed Value: Diagnostic studies report
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(DiagnosticReportLab | DiagnosticReportImaging) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Medications 0..1 BackboneElement The section lists the medications prescribed to the patient during their hospital stay, including dosage, frequency, and administration route.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003606003
....... display 1..1 string Representation defined by the system
Fixed Value: Medication history section
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(MedicationRequest) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Procedures 0..1 BackboneElement The section records any surgical or medical procedures performed on the patient during their admission.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003640003
....... display 1..1 string Representation defined by the system
Fixed Value: History of past procedure section
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(Procedure) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:CarePlan 0..1 BackboneElement The section outlines the care plan developed for the patient, including treatment goals, planned interventions.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 734163000
....... display 1..1 string Representation defined by the system
Fixed Value: Care plan
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(CarePlan) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:DocumentReference 0..1 BackboneElement The section contains references to documents related to the patient's discharge summary.
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 373942005
....... display 1..1 string Representation defined by the system
Fixed Value: Discharge summary
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the section
..... entry S 0..* Reference(DocumentReference) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 373942005
..... display Σ 1..1 string Representation defined by the system
Fixed Value: Discharge summary
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text SΣ 0..1 string Plain text representation of the concept
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Patient) Who and/or what the composition is about
.... id 0..1 string Unique id for inter-element referencing
.... 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 Σ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the composition
... title Σ 1..1 string Human Readable name/title
... confidentiality Σ 0..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... attester S 0..* BackboneElement Attests to accuracy of composition
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... time 0..1 dateTime When the composition was attested
.... party 0..1 Reference(RelatedPerson | Practitioner | PractitionerRole | Patient | Organization) Who attested the composition
... custodian Σ 0..1 Reference(Organization) Organization which maintains the composition
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... Slices for section SC 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open At End by value:code.coding.code
Constraints: cmp-1, cmp-2
.... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 The section captures the primary reasons for the patient's admission, detailing the main symptoms or issues reported by the patient.
Constraints: cmp-1, cmp-2
..... 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 1..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(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 The section records the findings from the physical examination conducted by the healthcare provider, including vital signs and other physical assessments.
Constraints: cmp-1, cmp-2
..... 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 1..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(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 The section includes details about the patient's allergies and adverse reactions to medications, foods, or other substances.
Constraints: cmp-1, cmp-2
..... 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 1..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(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 The section records the patient's past medical history, including previous illnesses, surgeries etc.
Constraints: cmp-1, cmp-2
..... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003642006
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Past medical history section
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 | 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:FamilyHistory C 0..1 BackboneElement The section records patient's relevant family medical history that may impact the patient’s health such as Diabetes etc.
Constraints: cmp-1, cmp-2
..... 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 1..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(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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:Investigations C 0..1 BackboneElement The section includes information about diagnostic tests and investigations carried out during the patient's admission, such as lab tests, imaging studies, and other diagnostic procedures.
Constraints: cmp-1, cmp-2
..... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 721981007
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Diagnostic studies report
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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(DiagnosticReportLab | DiagnosticReportImaging) 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 The section lists the medications prescribed to the patient during their hospital stay, including dosage, frequency, and administration route.
Constraints: cmp-1, cmp-2
..... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003606003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Medication history section
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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(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:Procedures C 0..1 BackboneElement The section records any surgical or medical procedures performed on the patient during their admission.
Constraints: cmp-1, cmp-2
..... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 1003640003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: History of past procedure section
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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:CarePlan C 0..1 BackboneElement The section outlines the care plan developed for the patient, including treatment goals, planned interventions.
Constraints: cmp-1, cmp-2
..... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 734163000
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Care plan
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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(CarePlan) 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 The section contains references to documents related to the patient's discharge summary.
Constraints: cmp-1, cmp-2
..... 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 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: 373942005
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Discharge summary
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages|4.0.1
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
From the FHIR Standard
Composition.typepreferredFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes|4.0.1
From the FHIR Standard
Composition.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes|4.0.1
From the FHIR Standard
Composition.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.confidentialityrequiredv3.ConfidentialityClassification
http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26
From the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
From the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:ChiefComplaints.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:ChiefComplaints.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:ChiefComplaints.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:ChiefComplaints.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:ChiefComplaints.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:PhysicalExamination.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:PhysicalExamination.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:PhysicalExamination.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:PhysicalExamination.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:PhysicalExamination.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:Allergies.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Allergies.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:Allergies.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:Allergies.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:Allergies.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:MedicalHistory.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:MedicalHistory.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:MedicalHistory.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:MedicalHistory.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:MedicalHistory.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:FamilyHistory.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:FamilyHistory.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:FamilyHistory.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:FamilyHistory.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:FamilyHistory.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:Investigations.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Investigations.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:Investigations.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:Investigations.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:Investigations.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:Medications.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Medications.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:Medications.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:Medications.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:Medications.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:Procedures.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Procedures.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:Procedures.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:Procedures.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:Procedures.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:CarePlan.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:CarePlan.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:CarePlan.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:CarePlan.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:CarePlan.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:DocumentReference.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:DocumentReference.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:DocumentReference.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:DocumentReference.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:DocumentReference.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.section, Composition.section:ChiefComplaints, Composition.section:PhysicalExamination, Composition.section:Allergies, Composition.section:MedicalHistory, Composition.section:FamilyHistory, Composition.section:Investigations, Composition.section:Medications, Composition.section:Procedures, Composition.section:CarePlan, Composition.section:DocumentReferenceA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.section, Composition.section:ChiefComplaints, Composition.section:PhysicalExamination, Composition.section:Allergies, Composition.section:MedicalHistory, Composition.section:FamilyHistory, Composition.section:Investigations, Composition.section:Medications, Composition.section:Procedures, Composition.section:CarePlan, Composition.section:DocumentReferenceA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Composition

Summary

Mandatory: 8 elements(40 nested mandatory elements)
Must-Support: 38 elements
Fixed: 33 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Composition.section (Open at End)

 

Other representations of profile: CSV, Excel, Schematron