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: OPConsultRecord

Official URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/OPConsultRecord Version: 6.5.0
Draft as of 2020-09-17 Computable Name: OPConsultRecord

The Clinical Artifact represents the outpatient visit consultation note which may include clinical information on any OP examinations, procedures along with medication administered, and advice that can be shared across the health ecosystem.

This profile sets minimum expectations for the OPConsultRecord to logical package and provide a single coherent statement of meaning, establish its own context that has clinical attestation for a clinical record. It identifies the mandatory core elements, vocabularies and value sets which SHALL be present in the Composition resource when using this profile.

Examples

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: 371530004
..... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical consultation report
.... 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 SΣ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the composition
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... title SΣ 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 | Patient | Practitioner | PractitionerRole | 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 Composition is broken into sections
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 | Organization | Patient | PractitionerRole | Practitioner) 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 patient's body's basic functions such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area 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: 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 | Organization | Patient | PractitionerRole | Practitioner) 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 records any known allergies patient has, including medication, food, or environmental triggers
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 | Organization | Patient | PractitionerRole | Practitioner) 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 patient’s past medical history, including previous diagnoses and treatments.
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: 371529009
....... display Σ 1..1 string Representation defined by the system
Fixed Value: History and physical report
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry SC 0..* Reference(Condition | Procedure) 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 | Organization | Patient | PractitionerRole | Practitioner) 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:InvestigationAdvice C 0..1 BackboneElement The section records information about recommended diagnostic tests or services.
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: 721963009
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Order document
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry SC 0..* Reference(ServiceRequest) 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 records any medications prescribed or currently taken 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: 721912009
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Medication summary document
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry SC 0..* Reference(MedicationStatement | MedicationRequest) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:FollowUp C 0..1 BackboneElement The section records instructions for follow-up consultations or care.
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: 390906007
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Follow-up encounter
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry SC 0..* Reference(Appointment) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Procedure C 0..1 BackboneElement The section records any procedures performed.
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: 371525003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical procedure report
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:Referral C 0..1 BackboneElement The section records information about any referrals made to other healthcare providers or specialists.
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: 306206005
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Referral to service
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry SC 0..* Reference(ServiceRequest) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:OtherObservations C 0..1 BackboneElement The section records additional observations that do not fit into other sections.
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: 404684003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical finding
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:DocumentReference C 0..1 BackboneElement The section records documents, such as PDFs or images, relevant to the consultation.
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: 371530004
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical consultation report
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:InvestigationAdvice.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:FollowUp.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Procedure.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Referral.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:OtherObservations.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:InvestigationAdvice, Composition.section:Medications, Composition.section:FollowUp, Composition.section:Procedure, Composition.section:Referral, Composition.section:OtherObservations, 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:InvestigationAdvice, Composition.section:Medications, Composition.section:FollowUp, Composition.section:Procedure, Composition.section:Referral, Composition.section:OtherObservations, 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: 371530004
..... display 1..1 string Representation defined by the system
Fixed Value: Clinical consultation report
.... text S 0..1 string Plain text representation of the concept
... subject S 1..1 Reference(Patient) Who and/or what the composition is about
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... date S 1..1 dateTime Composition editing time
... author S 1..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the composition
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... title S 1..1 string Human Readable name/title
... attester S 0..* BackboneElement Attests to accuracy of composition
.... party 0..1 Reference(RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who attested the composition
... custodian 0..1 Reference(Organization) Organization which maintains the composition
... Slices for section S 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open At End by value:code.coding.code
.... section:ChiefComplaints 0..1 BackboneElement Composition is broken into sections
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 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 | Organization | Patient | PractitionerRole | Practitioner) 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 patient's body's basic functions such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area 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: 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 | Organization | Patient | PractitionerRole | Practitioner) 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 records any known allergies patient has, including medication, food, or environmental triggers
..... 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 | Organization | Patient | PractitionerRole | Practitioner) 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 patient’s past medical history, including previous diagnoses and treatments.
..... 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: 371529009
....... display 1..1 string Representation defined by the system
Fixed Value: History and physical report
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry S 0..* Reference(Condition | Procedure) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:FamilyHistory 0..1 BackboneElement 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 | Organization | Patient | PractitionerRole | Practitioner) 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:InvestigationAdvice 0..1 BackboneElement The section records information about recommended diagnostic tests or services.
..... 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: 721963009
....... display 1..1 string Representation defined by the system
Fixed Value: Order document
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry S 0..* Reference(ServiceRequest) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Medications 0..1 BackboneElement The section records any medications prescribed or currently taken 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: 721912009
....... display 1..1 string Representation defined by the system
Fixed Value: Medication summary document
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry S 0..* Reference(MedicationStatement | MedicationRequest) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:FollowUp 0..1 BackboneElement The section records instructions for follow-up consultations or care.
..... 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: 390906007
....... display 1..1 string Representation defined by the system
Fixed Value: Follow-up encounter
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry S 0..* Reference(Appointment) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Procedure 0..1 BackboneElement The section records any procedures performed.
..... 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: 371525003
....... display 1..1 string Representation defined by the system
Fixed Value: Clinical procedure report
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:Referral 0..1 BackboneElement The section records information about any referrals made to other healthcare providers or specialists.
..... 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: 306206005
....... display 1..1 string Representation defined by the system
Fixed Value: Referral to service
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry S 0..* Reference(ServiceRequest) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:OtherObservations 0..1 BackboneElement The section records additional observations that do not fit into other sections.
..... 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: 404684003
....... display 1..1 string Representation defined by the system
Fixed Value: Clinical finding
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:DocumentReference 0..1 BackboneElement The section records documents, such as PDFs or images, relevant to the consultation.
..... 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: 371530004
....... display 1..1 string Representation defined by the system
Fixed Value: Clinical consultation report
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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: 371530004
..... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical consultation report
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text SΣ 0..1 string Plain text representation of the concept
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Patient) Who and/or what the composition is about
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter SΣ 1..1 Reference(Encounter) Context of the Composition
... date SΣ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the composition
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... title SΣ 1..1 string Human Readable name/title
... confidentiality Σ 0..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... attester S 0..* BackboneElement Attests to accuracy of composition
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... time 0..1 dateTime When the composition was attested
.... party 0..1 Reference(RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who attested the composition
... custodian Σ 0..1 Reference(Organization) Organization which maintains the composition
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... Slices for section SC 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open At End by value:code.coding.code
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 Composition is broken into sections
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 | Organization | Patient | PractitionerRole | Practitioner) 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 patient's body's basic functions such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area 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: 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 | Organization | Patient | PractitionerRole | Practitioner) 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 records any known allergies patient has, including medication, food, or environmental triggers
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 | Organization | Patient | PractitionerRole | Practitioner) 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 patient’s past medical history, including previous diagnoses and treatments.
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: 371529009
....... display Σ 1..1 string Representation defined by the system
Fixed Value: History and physical report
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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 | Procedure) A reference to data that supports this section
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:FamilyHistory C 0..1 BackboneElement 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 | Organization | Patient | PractitionerRole | Practitioner) 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:InvestigationAdvice C 0..1 BackboneElement The section records information about recommended diagnostic tests or services.
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: 721963009
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Order document
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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(ServiceRequest) A reference to data that supports this section
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:Medications C 0..1 BackboneElement The section records any medications prescribed or currently taken 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: 721912009
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Medication summary document
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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(MedicationStatement | MedicationRequest) A reference to data that supports this section
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:FollowUp C 0..1 BackboneElement The section records instructions for follow-up consultations or care.
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: 390906007
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Follow-up encounter
....... 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 | Organization | Patient | PractitionerRole | Practitioner) 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(Appointment) A reference to data that supports this section
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:Procedure C 0..1 BackboneElement The section records any procedures performed.
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: 371525003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical procedure report
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:Referral C 0..1 BackboneElement The section records information about any referrals made to other healthcare providers or specialists.
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: 306206005
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Referral to service
....... 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 | Organization | Patient | PractitionerRole | Practitioner) 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(ServiceRequest) A reference to data that supports this section
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:OtherObservations C 0..1 BackboneElement The section records additional observations that do not fit into other sections.
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: 404684003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical finding
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:DocumentReference C 0..1 BackboneElement The section records documents, such as PDFs or images, relevant to the consultation.
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: 371530004
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical consultation report
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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.author.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:InvestigationAdvice.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:InvestigationAdvice.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:InvestigationAdvice.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:InvestigationAdvice.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:InvestigationAdvice.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:FollowUp.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:FollowUp.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:FollowUp.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:FollowUp.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:FollowUp.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:Procedure.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Procedure.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:Procedure.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:Procedure.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:Procedure.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:Referral.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Referral.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:Referral.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:Referral.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:Referral.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:OtherObservations.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:OtherObservations.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:OtherObservations.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:OtherObservations.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:OtherObservations.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:InvestigationAdvice, Composition.section:Medications, Composition.section:FollowUp, Composition.section:Procedure, Composition.section:Referral, Composition.section:OtherObservations, 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:InvestigationAdvice, Composition.section:Medications, Composition.section:FollowUp, Composition.section:Procedure, Composition.section:Referral, Composition.section:OtherObservations, 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: 9 elements(48 nested mandatory elements)
Must-Support: 46 elements
Fixed: 39 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: 371530004
..... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical consultation report
.... 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 SΣ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the composition
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... title SΣ 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 | Patient | Practitioner | PractitionerRole | 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 Composition is broken into sections
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 | Organization | Patient | PractitionerRole | Practitioner) 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 patient's body's basic functions such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area 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: 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 | Organization | Patient | PractitionerRole | Practitioner) 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 records any known allergies patient has, including medication, food, or environmental triggers
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 | Organization | Patient | PractitionerRole | Practitioner) 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 patient’s past medical history, including previous diagnoses and treatments.
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: 371529009
....... display Σ 1..1 string Representation defined by the system
Fixed Value: History and physical report
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry SC 0..* Reference(Condition | Procedure) 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 | Organization | Patient | PractitionerRole | Practitioner) 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:InvestigationAdvice C 0..1 BackboneElement The section records information about recommended diagnostic tests or services.
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: 721963009
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Order document
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry SC 0..* Reference(ServiceRequest) 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 records any medications prescribed or currently taken 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: 721912009
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Medication summary document
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry SC 0..* Reference(MedicationStatement | MedicationRequest) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:FollowUp C 0..1 BackboneElement The section records instructions for follow-up consultations or care.
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: 390906007
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Follow-up encounter
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry SC 0..* Reference(Appointment) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Procedure C 0..1 BackboneElement The section records any procedures performed.
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: 371525003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical procedure report
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:Referral C 0..1 BackboneElement The section records information about any referrals made to other healthcare providers or specialists.
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: 306206005
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Referral to service
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry SC 0..* Reference(ServiceRequest) A reference to data that supports this section
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... section:OtherObservations C 0..1 BackboneElement The section records additional observations that do not fit into other sections.
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: 404684003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical finding
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:DocumentReference C 0..1 BackboneElement The section records documents, such as PDFs or images, relevant to the consultation.
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: 371530004
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical consultation report
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:InvestigationAdvice.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:FollowUp.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Procedure.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Referral.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:OtherObservations.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:InvestigationAdvice, Composition.section:Medications, Composition.section:FollowUp, Composition.section:Procedure, Composition.section:Referral, Composition.section:OtherObservations, 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:InvestigationAdvice, Composition.section:Medications, Composition.section:FollowUp, Composition.section:Procedure, Composition.section:Referral, Composition.section:OtherObservations, 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: 371530004
..... display 1..1 string Representation defined by the system
Fixed Value: Clinical consultation report
.... text S 0..1 string Plain text representation of the concept
... subject S 1..1 Reference(Patient) Who and/or what the composition is about
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... date S 1..1 dateTime Composition editing time
... author S 1..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the composition
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... title S 1..1 string Human Readable name/title
... attester S 0..* BackboneElement Attests to accuracy of composition
.... party 0..1 Reference(RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who attested the composition
... custodian 0..1 Reference(Organization) Organization which maintains the composition
... Slices for section S 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open At End by value:code.coding.code
.... section:ChiefComplaints 0..1 BackboneElement Composition is broken into sections
..... code
...... coding S 0..1 Coding Code defined by a terminology system
....... system 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 | Organization | Patient | PractitionerRole | Practitioner) 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 patient's body's basic functions such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area 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: 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 | Organization | Patient | PractitionerRole | Practitioner) 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 records any known allergies patient has, including medication, food, or environmental triggers
..... 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 | Organization | Patient | PractitionerRole | Practitioner) 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 patient’s past medical history, including previous diagnoses and treatments.
..... 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: 371529009
....... display 1..1 string Representation defined by the system
Fixed Value: History and physical report
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry S 0..* Reference(Condition | Procedure) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:FamilyHistory 0..1 BackboneElement 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 | Organization | Patient | PractitionerRole | Practitioner) 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:InvestigationAdvice 0..1 BackboneElement The section records information about recommended diagnostic tests or services.
..... 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: 721963009
....... display 1..1 string Representation defined by the system
Fixed Value: Order document
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry S 0..* Reference(ServiceRequest) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Medications 0..1 BackboneElement The section records any medications prescribed or currently taken 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: 721912009
....... display 1..1 string Representation defined by the system
Fixed Value: Medication summary document
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry S 0..* Reference(MedicationStatement | MedicationRequest) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:FollowUp 0..1 BackboneElement The section records instructions for follow-up consultations or care.
..... 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: 390906007
....... display 1..1 string Representation defined by the system
Fixed Value: Follow-up encounter
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry S 0..* Reference(Appointment) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:Procedure 0..1 BackboneElement The section records any procedures performed.
..... 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: 371525003
....... display 1..1 string Representation defined by the system
Fixed Value: Clinical procedure report
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:Referral 0..1 BackboneElement The section records information about any referrals made to other healthcare providers or specialists.
..... 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: 306206005
....... display 1..1 string Representation defined by the system
Fixed Value: Referral to service
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) Who and/or what authored the section
..... entry S 0..* Reference(ServiceRequest) A reference to data that supports this section
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
.... section:OtherObservations 0..1 BackboneElement The section records additional observations that do not fit into other sections.
..... 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: 404684003
....... display 1..1 string Representation defined by the system
Fixed Value: Clinical finding
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:DocumentReference 0..1 BackboneElement The section records documents, such as PDFs or images, relevant to the consultation.
..... 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: 371530004
....... display 1..1 string Representation defined by the system
Fixed Value: Clinical consultation report
...... text S 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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: 371530004
..... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical consultation report
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text SΣ 0..1 string Plain text representation of the concept
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Patient) Who and/or what the composition is about
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter SΣ 1..1 Reference(Encounter) Context of the Composition
... date SΣ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who and/or what authored the composition
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... title SΣ 1..1 string Human Readable name/title
... confidentiality Σ 0..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... attester S 0..* BackboneElement Attests to accuracy of composition
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... time 0..1 dateTime When the composition was attested
.... party 0..1 Reference(RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) Who attested the composition
... custodian Σ 0..1 Reference(Organization) Organization which maintains the composition
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... Slices for section SC 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open At End by value:code.coding.code
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 Composition is broken into sections
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 | Organization | Patient | PractitionerRole | Practitioner) 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 patient's body's basic functions such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area 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: 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 | Organization | Patient | PractitionerRole | Practitioner) 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 records any known allergies patient has, including medication, food, or environmental triggers
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 | Organization | Patient | PractitionerRole | Practitioner) 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 patient’s past medical history, including previous diagnoses and treatments.
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: 371529009
....... display Σ 1..1 string Representation defined by the system
Fixed Value: History and physical report
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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 | Procedure) A reference to data that supports this section
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:FamilyHistory C 0..1 BackboneElement 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 | Organization | Patient | PractitionerRole | Practitioner) 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:InvestigationAdvice C 0..1 BackboneElement The section records information about recommended diagnostic tests or services.
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: 721963009
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Order document
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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(ServiceRequest) A reference to data that supports this section
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:Medications C 0..1 BackboneElement The section records any medications prescribed or currently taken 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: 721912009
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Medication summary document
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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(MedicationStatement | MedicationRequest) A reference to data that supports this section
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:FollowUp C 0..1 BackboneElement The section records instructions for follow-up consultations or care.
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: 390906007
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Follow-up encounter
....... 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 | Organization | Patient | PractitionerRole | Practitioner) 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(Appointment) A reference to data that supports this section
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:Procedure C 0..1 BackboneElement The section records any procedures performed.
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: 371525003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical procedure report
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:Referral C 0..1 BackboneElement The section records information about any referrals made to other healthcare providers or specialists.
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: 306206005
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Referral to service
....... 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 | Organization | Patient | PractitionerRole | Practitioner) 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(ServiceRequest) A reference to data that supports this section
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:OtherObservations C 0..1 BackboneElement The section records additional observations that do not fit into other sections.
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: 404684003
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical finding
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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:DocumentReference C 0..1 BackboneElement The section records documents, such as PDFs or images, relevant to the consultation.
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: 371530004
....... display Σ 1..1 string Representation defined by the system
Fixed Value: Clinical consultation report
....... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
...... text SΣ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Device | RelatedPerson | Organization | Patient | PractitionerRole | Practitioner) 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.author.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:InvestigationAdvice.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:InvestigationAdvice.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:InvestigationAdvice.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:InvestigationAdvice.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:InvestigationAdvice.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:FollowUp.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:FollowUp.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:FollowUp.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:FollowUp.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:FollowUp.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:Procedure.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Procedure.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:Procedure.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:Procedure.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:Procedure.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:Referral.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:Referral.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:Referral.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:Referral.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:Referral.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1
From the FHIR Standard
Composition.section:OtherObservations.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1
From the FHIR Standard
Composition.section:OtherObservations.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section:OtherObservations.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order|4.0.1
From the FHIR Standard
Composition.section:OtherObservations.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types|4.0.1
From the FHIR Standard
Composition.section:OtherObservations.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:InvestigationAdvice, Composition.section:Medications, Composition.section:FollowUp, Composition.section:Procedure, Composition.section:Referral, Composition.section:OtherObservations, 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:InvestigationAdvice, Composition.section:Medications, Composition.section:FollowUp, Composition.section:Procedure, Composition.section:Referral, Composition.section:OtherObservations, 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: 9 elements(48 nested mandatory elements)
Must-Support: 46 elements
Fixed: 39 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