LACPass International Patient Summary (IPS) Guide
0.1.0 - ci-build
LACPass International Patient Summary (IPS) Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
Official URL: http://lacpass.racsel.org/StructureDefinition/lac-composition-ddcc | Version: 0.1.0 | |||
Active as of 2024-04-12 | Computable Name: LAC_Composition_DDCC |
LACPass Patient Summary Composition resource. This profile derives from the International Patient summary with customizations for the entries to use the profiles defined in this implementation guide and the necessary to implement the DDCC standard.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CompositionUvIps
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | CompositionUvIps | |||
subject | 1..1 | Reference(LAC_Patient) | Who and/or what the composition is about | |
custodian | 1..1 | Reference(LAC_Organization) | Organization which maintains the composition | |
section | 4..* | BackboneElement | Sections composing the IPS | |
section:sectionImmunizations | 1..1 | BackboneElement | IPS Immunizations Section | |
entry | 1..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. | |
entry:immunization | 1..1 | Reference(LAC_Immunization) | A reference to data that supports this section | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | CompositionUvIps | International Patient Summary composition | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | SΣ | 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 | S | 1..1 | CodeableConceptIPS | Kind of composition ("Patient Summary") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 60591-5 | |
subject | SΣ | 1..1 | Reference(LAC_Patient) | Who and/or what the composition is about |
reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
date | SΣ | 1..1 | dateTime | Composition editing time |
author | SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the IPS |
title | SΣ | 1..1 | string | International Patient Summary |
attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
mode | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. |
time | S | 0..1 | dateTime | When the composition was attested |
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
custodian | SΣ | 1..1 | Reference(LAC_Organization) | Organization which maintains the composition |
Slices for event | Σ | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by pattern:code |
event:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
event:careProvisioningEvent | SΣ | 0..1 | BackboneElement | The care provisioning being documented |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | SΣ | 1..1 | 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. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PCPR | |
period | SΣ | 0..1 | Period | The period covered by the documentation |
Slices for section | SC | 4..* | BackboneElement | Sections composing the IPS Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
section:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. |
text | SC | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:sectionMedications | SC | 1..1 | BackboneElement | IPS Medication Summary Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ips-comp-1: Either section.entry or emptyReason are present |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | S | 1..1 | string | Medication Summary section |
Slices for entry | SC | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() |
entry:medicationStatement | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section |
entry:medicationRequest | C | 0..* | Reference(Medication Request (IPS)) | A reference to data that supports this section |
section:sectionAllergies | SC | 1..1 | BackboneElement | IPS Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ips-comp-1: Either section.entry or emptyReason are present |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
Slices for entry | SC | 0..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by profile:resolve() |
entry:allergyOrIntolerance | SC | 0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section |
section:sectionProblems | SC | 1..1 | BackboneElement | IPS Problems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ips-comp-1: Either section.entry or emptyReason are present |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
Slices for entry | SC | 0..* | Reference(Condition | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:resolve() |
entry:problem | SC | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section |
section:sectionProceduresHx | SC | 0..1 | BackboneElement | IPS History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
Slices for entry | SC | 0..* | Reference(Procedure | DocumentReference) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by profile:resolve() |
entry:procedure | SC | 0..* | Reference(Procedure (IPS)) | A reference to data that supports this section |
section:sectionImmunizations | SC | 1..1 | BackboneElement | IPS Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
Slices for entry | SC | 1..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by profile:resolve() |
entry:immunization | SC | 1..1 | Reference(LAC_Immunization) | A reference to data that supports this section |
section:sectionMedicalDevices | SC | 0..1 | BackboneElement | IPS Medical Devices Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
Slices for entry | SC | 0..* | Reference(DeviceUseStatement | DocumentReference) | Patient history of medical device use. Slice: Unordered, Open by profile:resolve() |
entry:deviceStatement | SC | 0..* | Reference(Device Use Statement (IPS)) | A reference to data that supports this section |
section:sectionResults | SC | 0..1 | BackboneElement | IPS Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
Slices for entry | SC | 0..* | Reference(Observation | DiagnosticReport | DocumentReference) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Slice: Unordered, Open by type:resolve(), profile:resolve() |
entry:results-observation | SC | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section |
entry:results-diagnosticReport | SC | 0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this section |
section:sectionVitalSigns | C | 0..1 | BackboneElement | IPS Vital Signs Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
Slices for entry | C | 0..* | Reference(Observation | DocumentReference) | Notable vital signs or physical findings. Slice: Unordered, Open by profile:resolve() |
entry:vitalSign | C | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section |
section:sectionPastIllnessHx | C | 0..1 | BackboneElement | IPS History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
Slices for entry | C | 0..* | Reference(Condition | DocumentReference) | Conditions the patient suffered in the past. Slice: Unordered, Open by profile:resolve() |
entry:pastProblem | C | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section |
section:sectionFunctionalStatus | C | 0..1 | BackboneElement | IPS Functional Status cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
Slices for entry | C | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | Optional entry used to represent disabilities and functional assessments Slice: Unordered, Open by profile:resolve() |
entry:disability | C | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section |
entry:functionalAssessment | C | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section |
section:sectionPlanOfCare | C | 0..1 | BackboneElement | IPS Plan of Care Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
Slices for entry | C | 0..* | Reference(CarePlan | DocumentReference) | Optional entry used to represent structured care plans Slice: Unordered, Open by profile:resolve() |
entry:carePlan | C | 0..* | Reference(CarePlan) | A reference to data that supports this section |
section:sectionSocialHistory | C | 0..1 | BackboneElement | IPS Social History Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
Slices for entry | C | 0..* | Reference(Observation | DocumentReference) | Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) Slice: Unordered, Open by profile:resolve() |
entry:smokingTobaccoUse | C | 0..1 | Reference(Observation - SH: tobacco use) | A reference to data that supports this section |
entry:alcoholUse | C | 0..1 | Reference(Observation - SH: alcohol use) | A reference to data that supports this section |
section:sectionPregnancyHx | C | 0..1 | BackboneElement | IPS History of Pregnancy Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
Slices for entry | C | 0..* | Reference(Observation | DocumentReference) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. Slice: Unordered, Open by profile:resolve() |
entry:pregnancyStatus | C | 0..* | Reference(Observation - Pregnancy: status) | A reference to data that supports this section |
entry:pregnancyOutcomeSummary | C | 0..* | Reference(Observation - Pregnancy: outcome) | A reference to data that supports this section |
section:sectionAdvanceDirectives | C | 0..1 | BackboneElement | IPS Advance Directives Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | 1..1 | string | Label for section (e.g. for ToC) | |
Slices for entry | C | 0..* | Reference(Consent | DocumentReference) | Narrative description of the patient's advance directive. Slice: Unordered, Open by profile:resolve() |
entry:advanceDirectivesConsent | C | 0..* | Reference(Consent) | A reference to data that supports this section |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | Pattern: LOINC code 60591-5http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | |
Composition.event:careProvisioningEvent.code | example | Pattern: PCPRhttp://terminology.hl7.org/ValueSet/v3-ActCode | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
cmp-1 | error | Composition.section, Composition.section:sectionMedications, Composition.section:sectionAllergies, Composition.section:sectionProblems, Composition.section:sectionProceduresHx, Composition.section:sectionImmunizations, Composition.section:sectionMedicalDevices, Composition.section:sectionResults, Composition.section:sectionVitalSigns, Composition.section:sectionPastIllnessHx, Composition.section:sectionFunctionalStatus, Composition.section:sectionPlanOfCare, Composition.section:sectionSocialHistory, Composition.section:sectionPregnancyHx, Composition.section:sectionAdvanceDirectives | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
cmp-2 | error | Composition.section, Composition.section:sectionMedications, Composition.section:sectionAllergies, Composition.section:sectionProblems, Composition.section:sectionProceduresHx, Composition.section:sectionImmunizations, Composition.section:sectionMedicalDevices, Composition.section:sectionResults, Composition.section:sectionVitalSigns, Composition.section:sectionPastIllnessHx, Composition.section:sectionFunctionalStatus, Composition.section:sectionPlanOfCare, Composition.section:sectionSocialHistory, Composition.section:sectionPregnancyHx, Composition.section:sectionAdvanceDirectives | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Composition | If 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-4 | error | Composition | If 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-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ips-comp-1 | error | Composition.section:sectionMedications, Composition.section:sectionAllergies, Composition.section:sectionProblems | Either section.entry or emptyReason are present : (entry.reference.exists() or emptyReason.exists()) |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | CompositionUvIps | International Patient Summary composition | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation | ||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 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 | S | 1..1 | CodeableConceptIPS | Kind of composition ("Patient Summary") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 60591-5 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 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(LAC_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 | SΣC | 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 | Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
date | SΣ | 1..1 | dateTime | Composition editing time | ||||
author | SΣ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the IPS | ||||
title | SΣ | 1..1 | string | International Patient Summary | ||||
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 | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | ||||
time | S | 0..1 | dateTime | When the composition was attested | ||||
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||
custodian | SΣ | 1..1 | Reference(LAC_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 | Composition (IPS)) | |||||||
Slices for event | Σ | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by pattern:code | ||||
event: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 | ||||
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 | ||||
event:careProvisioningEvent | SΣ | 0..1 | BackboneElement | The care provisioning 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 | SΣ | 1..1 | 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. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PCPR | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
period | SΣ | 0..1 | Period | The period covered by the documentation | ||||
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
Slices for section | SC | 4..* | BackboneElement | Sections composing the IPS Slice: Unordered, Open by pattern:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text 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 | SC | 1..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section:sectionMedications | SC | 1..1 | BackboneElement | IPS Medication Summary Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ips-comp-1: Either section.entry or emptyReason are present | ||||
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 | S | 1..1 | string | Medication Summary section | ||||
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | SC | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() | ||||
entry:medicationStatement | C | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | ||||
entry:medicationRequest | C | 0..* | Reference(Medication Request (IPS)) | 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:sectionAllergies | SC | 1..1 | BackboneElement | IPS Allergies and Intolerances Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ips-comp-1: Either section.entry or emptyReason are present | ||||
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 | S | 1..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. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | SC | 0..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by profile:resolve() | ||||
entry:allergyOrIntolerance | SC | 0..* | Reference(Allergy Intolerance (IPS)) | 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:sectionProblems | SC | 1..1 | BackboneElement | IPS Problems Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ips-comp-1: Either section.entry or emptyReason are present | ||||
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 | S | 1..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. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | SC | 0..* | Reference(Condition | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:resolve() | ||||
entry:problem | SC | 0..* | Reference(Condition (IPS)) | 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:sectionProceduresHx | SC | 0..1 | BackboneElement | IPS History of Procedures Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..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. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | SC | 0..* | Reference(Procedure | DocumentReference) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by profile:resolve() | ||||
entry:procedure | SC | 0..* | Reference(Procedure (IPS)) | 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:sectionImmunizations | SC | 1..1 | BackboneElement | IPS Immunizations Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..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. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | SC | 1..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by profile:resolve() | ||||
entry:immunization | SC | 1..1 | Reference(LAC_Immunization) | 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:sectionMedicalDevices | SC | 0..1 | BackboneElement | IPS Medical Devices Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..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. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | SC | 0..* | Reference(DeviceUseStatement | DocumentReference) | Patient history of medical device use. Slice: Unordered, Open by profile:resolve() | ||||
entry:deviceStatement | SC | 0..* | Reference(Device Use Statement (IPS)) | 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:sectionResults | SC | 0..1 | BackboneElement | IPS Results Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | S | 1..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. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | SC | 0..* | Reference(Observation | DiagnosticReport | DocumentReference) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Slice: Unordered, Open by type:resolve(), profile:resolve() | ||||
entry:results-observation | SC | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section | ||||
entry:results-diagnosticReport | SC | 0..* | Reference(DiagnosticReport (IPS)) | 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:sectionVitalSigns | C | 0..1 | BackboneElement | IPS Vital Signs Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..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. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Observation | DocumentReference) | Notable vital signs or physical findings. Slice: Unordered, Open by profile:resolve() | ||||
entry:vitalSign | C | 0..* | Reference(Vital Signs Profile) | 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:sectionPastIllnessHx | C | 0..1 | BackboneElement | IPS History of Past Illness Section cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..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. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
Slices for entry | C | 0..* | Reference(Condition | DocumentReference) | Conditions the patient suffered in the past. Slice: Unordered, Open by profile:resolve() | ||||
entry:pastProblem | C | 0..* | Reference(Condition (IPS)) | 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:sectionFunctionalStatus | C | 0..1 | BackboneElement | IPS Functional Status cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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 | 1..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. Required Pattern: At least the following | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||