Mongolian HDIT Implementation guide
1.0.0 - Review
Mongolian HDIT Implementation guide
1.0.0 - Review
Mongolian HDIT Implementation guide - Local Development build (v1.0.0). See the Directory of published versions
Documentation of an ambulance medical encounter. This documentation covers examinations, findings, treatment decisions and information about discharge from ambulance care to home, another healthcare provider or other destination.
The official URL for this profile is:
http://fhir.mn/StructureDefinition/mng-ambulance-case-note
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
Summary
Mandatory: 25 elements (2 nested mandatory elements)
Must-Support: 35 elements
Fixed Value: 1 element
Prohibited: 6 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  type | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) 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: 15507-7 | |
 display | 1..1 | string | Representation defined by the system Fixed Value: Emergency department Progress note | |
 subject | S | 1..1 | Reference(PatientMn) | Who and/or what the composition is about |
| encounter | S | 1..1 | Reference(AmbulanceEncounterMn) | Context of the Composition |
| date | S | 1..1 | dateTime | Composition editing time |
| confidentiality | S | 0..0 | ||
| attester | S | 0..0 | ||
| custodian | S | 0..0 | ||
| relatesTo | S | 0..0 | ||
| event | S | 0..0 | ||
 section | 12..* | (Slice Definition) | Composition is broken into sections Slice: Unordered, Open by value:title | |
  section:anamnesis | S | 1..1 | BackboneElement | Composition is broken into sections |
   extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
 extension:anamnesis-giver | 0..* | Extension | Extension | |
 extension | 0..0 | |||
| url | 1..1 | uri | "anamnesis-giver" | |
 value[x] | 0..1 | Reference(PractitionerRoleMn | Related person) | Value of extension | |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Anamnesis | |
| entry | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
 entry:pain-anamnesis | S | 0..1 | Reference(Pain anamnesis) | A reference to data that supports this section |
| entry:history-of-illness | S | 0..1 | Reference(HistoryOfPresentIllness) | A reference to data that supports this section |
 entry:blood-type | S | 0..1 | Reference(BloodType-mn) | A reference to data that supports this section |
 section | 0..* | (Slice Definition) | Nested Section Slice: Unordered, Open by value:title | |
| section:female-reproductive-system-anamnesis | 0..1 | BackboneElement | Nested Section | |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Female reproductive system anamnesis | |
| entry | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:last-menstrual-period | S | 0..1 | Reference(LastMenstrualPeriod) | A reference to data that supports this section |
| entry:pregnancy-status | S | 0..1 | Reference(PregnancyStatus) | A reference to data that supports this section |
| entry:pregnancy-week | S | 0..1 | Reference(PregnancyWeek) | A reference to data that supports this section |
| entry:menopause | S | 0..1 | Reference(MenopauseStatus) | A reference to data that supports this section |
 section:epidemiological-anamnesis | 0..1 | BackboneElement | Nested Section | |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Epidemiological anamnesis | |
| entry | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:contact-skin-rash | S | 0..1 | Reference(Resource) | A reference to data that supports this section |
| entry:travelled-abroad | S | 0..1 | Reference(Resource) | A reference to data that supports this section |
| entry:contact-infectious-disease | S | 0..1 | Reference(Resource) | A reference to data that supports this section |
| section:adverse-reaction | S | 1..1 | BackboneElement | Composition is broken into sections |
| section:allergies | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Allergy and adverse reaction | |
| entry | S | 0..* | Reference(AllergyIntoleranceMn) | A reference to data that supports this section |
| section:first-visit | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: First visit | |
| entry | S | 0..* | Reference(FirstVisitMn) | A reference to data that supports this section |
| section:vital-sign | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital sign | |
| entry | S | 0..* | Reference(VitalSignsMn) | A reference to data that supports this section |
| section:triage | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Triage | |
| entry | S | 0..* | Reference(TriageMn) | A reference to data that supports this section |
| section:treatment-plan | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Treatment plan | |
| entry | 0..* | Reference(ServiceRequest) | A reference to data that supports this section | |
| section:physicians-note | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Progress note/Physician note |
| entry | 0..* | Reference(ProgressNoteMn) | A reference to data that supports this section | |
| section:imaging-test-study | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Imaging test study result | |
| entry | 0..* | Reference(ImagingReportMn) | A reference to data that supports this section | |
| section:laboratory-test-study | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Laboratory test study result | |
| entry | 0..* | Reference(LabReportMn) | A reference to data that supports this section | |
| section:medication-prescription | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Medication prescription | |
| entry | 0..* | Reference(MedicationRequestMn) | A reference to data that supports this section | |
| section:advice-to-patient | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Recommendation to a patient | |
| entry | 0..* | Reference(Communication) | A reference to data that supports this section | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | I | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation |
 id | Σ | 0..1 | string | Logical id of this artifact |
 meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
 modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..1 | Identifier | Version-independent identifier for the Composition |
| status | ?!ΣI | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required) |
| type | ΣI | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred) 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: 15507-7 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Emergency department Progress note | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| category | ΣI | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example) |
| subject | SΣI | 1..1 | Reference(PatientMn) | Who and/or what the composition is about |
| encounter | SΣI | 1..1 | Reference(AmbulanceEncounterMn) | Context of the Composition |
| date | SΣI | 1..1 | dateTime | Composition editing time |
| author | ΣI | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
| title | ΣI | 1..1 | string | Human Readable name/title |
| section | I | 12..* | (Slice Definition) | Composition is broken into sections Slice: Unordered, Open by value:title |
| section:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section Nested Section | |
| section:anamnesis | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
| extension:anamnesis-giver | I | 0..* | Extension | Extension |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..0 | ||
| url | 1..1 | uri | "anamnesis-giver" | |
| value[x] | I | 0..1 | Reference(PractitionerRoleMn | Related person) | Value of extension |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Anamnesis |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:pain-anamnesis | SI | 0..1 | Reference(Pain anamnesis) | A reference to data that supports this section |
| entry:history-of-illness | SI | 0..1 | Reference(HistoryOfPresentIllness) | A reference to data that supports this section |
| entry:blood-type | SI | 0..1 | Reference(BloodType-mn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | (Slice Definition) | Unknown reference to #Composition.section:anamnesis Nested Section Slice: Unordered, Open by value:title |
| section:female-reproductive-system-anamnesis | I | 0..1 | BackboneElement | Nested Section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Female reproductive system anamnesis |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:last-menstrual-period | SI | 0..1 | Reference(LastMenstrualPeriod) | A reference to data that supports this section |
| entry:pregnancy-status | SI | 0..1 | Reference(PregnancyStatus) | A reference to data that supports this section |
| entry:pregnancy-week | SI | 0..1 | Reference(PregnancyWeek) | A reference to data that supports this section |
| entry:menopause | SI | 0..1 | Reference(MenopauseStatus) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:anamnesis Nested Section | |
| section:epidemiological-anamnesis | I | 0..1 | BackboneElement | Nested Section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Epidemiological anamnesis |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:contact-skin-rash | SI | 0..1 | Reference(Resource) | A reference to data that supports this section |
| entry:travelled-abroad | SI | 0..1 | Reference(Resource) | A reference to data that supports this section |
| entry:contact-infectious-disease | SI | 0..1 | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:anamnesis Nested Section | |
| section:adverse-reaction | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:adverse-reaction Nested Section | |
| section:allergies | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Allergy and adverse reaction |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(AllergyIntoleranceMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:allergies Nested Section | |
| section:first-visit | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: First visit |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(FirstVisitMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:first-visit Nested Section | |
| section:vital-sign | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital sign |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(VitalSignsMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:vital-sign Nested Section | |
| section:triage | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Triage |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(TriageMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:triage Nested Section | |
| section:treatment-plan | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Treatment plan |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(ServiceRequest) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:treatment-plan Nested Section | |
| section:physicians-note | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | SI | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Progress note/Physician note |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(ProgressNoteMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:physicians-note Nested Section | |
| section:imaging-test-study | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Imaging test study result |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(ImagingReportMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:imaging-test-study Nested Section | |
| section:laboratory-test-study | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Laboratory test study result |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(LabReportMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:laboratory-test-study Nested Section | |
| section:medication-prescription | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Medication prescription |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(MedicationRequestMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:medication-prescription Nested Section | |
| section:advice-to-patient | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Recommendation to a patient |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(Communication) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:advice-to-patient Nested Section | |
| Documentation for this format | ||||
This structure is derived from Composition
Summary
Mandatory: 25 elements (2 nested mandatory elements)
Must-Support: 35 elements
Fixed Value: 1 element
Prohibited: 6 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| type | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) 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: 15507-7 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Emergency department Progress note | |
| subject | S | 1..1 | Reference(PatientMn) | Who and/or what the composition is about |
| encounter | S | 1..1 | Reference(AmbulanceEncounterMn) | Context of the Composition |
| date | S | 1..1 | dateTime | Composition editing time |
| confidentiality | S | 0..0 | ||
| attester | S | 0..0 | ||
| custodian | S | 0..0 | ||
| relatesTo | S | 0..0 | ||
| event | S | 0..0 | ||
| section | 12..* | (Slice Definition) | Composition is broken into sections Slice: Unordered, Open by value:title | |
| section:anamnesis | S | 1..1 | BackboneElement | Composition is broken into sections |
| extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:anamnesis-giver | 0..* | Extension | Extension | |
| extension | 0..0 | |||
| url | 1..1 | uri | "anamnesis-giver" | |
| value[x] | 0..1 | Reference(PractitionerRoleMn | Related person) | Value of extension | |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Anamnesis | |
| entry | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:pain-anamnesis | S | 0..1 | Reference(Pain anamnesis) | A reference to data that supports this section |
| entry:history-of-illness | S | 0..1 | Reference(HistoryOfPresentIllness) | A reference to data that supports this section |
| entry:blood-type | S | 0..1 | Reference(BloodType-mn) | A reference to data that supports this section |
| section | 0..* | (Slice Definition) | Nested Section Slice: Unordered, Open by value:title | |
| section:female-reproductive-system-anamnesis | 0..1 | BackboneElement | Nested Section | |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Female reproductive system anamnesis | |
| entry | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:last-menstrual-period | S | 0..1 | Reference(LastMenstrualPeriod) | A reference to data that supports this section |
| entry:pregnancy-status | S | 0..1 | Reference(PregnancyStatus) | A reference to data that supports this section |
| entry:pregnancy-week | S | 0..1 | Reference(PregnancyWeek) | A reference to data that supports this section |
| entry:menopause | S | 0..1 | Reference(MenopauseStatus) | A reference to data that supports this section |
| section:epidemiological-anamnesis | 0..1 | BackboneElement | Nested Section | |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Epidemiological anamnesis | |
| entry | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:contact-skin-rash | S | 0..1 | Reference(Resource) | A reference to data that supports this section |
| entry:travelled-abroad | S | 0..1 | Reference(Resource) | A reference to data that supports this section |
| entry:contact-infectious-disease | S | 0..1 | Reference(Resource) | A reference to data that supports this section |
| section:adverse-reaction | S | 1..1 | BackboneElement | Composition is broken into sections |
| section:allergies | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Allergy and adverse reaction | |
| entry | S | 0..* | Reference(AllergyIntoleranceMn) | A reference to data that supports this section |
| section:first-visit | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: First visit | |
| entry | S | 0..* | Reference(FirstVisitMn) | A reference to data that supports this section |
| section:vital-sign | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital sign | |
| entry | S | 0..* | Reference(VitalSignsMn) | A reference to data that supports this section |
| section:triage | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Triage | |
| entry | S | 0..* | Reference(TriageMn) | A reference to data that supports this section |
| section:treatment-plan | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Treatment plan | |
| entry | 0..* | Reference(ServiceRequest) | A reference to data that supports this section | |
| section:physicians-note | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Progress note/Physician note |
| entry | 0..* | Reference(ProgressNoteMn) | A reference to data that supports this section | |
| section:imaging-test-study | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Imaging test study result | |
| entry | 0..* | Reference(ImagingReportMn) | A reference to data that supports this section | |
| section:laboratory-test-study | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Laboratory test study result | |
| entry | 0..* | Reference(LabReportMn) | A reference to data that supports this section | |
| section:medication-prescription | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Medication prescription | |
| entry | 0..* | Reference(MedicationRequestMn) | A reference to data that supports this section | |
| section:advice-to-patient | S | 1..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Recommendation to a patient | |
| entry | 0..* | Reference(Communication) | A reference to data that supports this section | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | I | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..1 | Identifier | Version-independent identifier for the Composition |
| status | ?!ΣI | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required) |
| type | ΣI | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred) 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: 15507-7 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Emergency department Progress note | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| category | ΣI | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example) |
| subject | SΣI | 1..1 | Reference(PatientMn) | Who and/or what the composition is about |
| encounter | SΣI | 1..1 | Reference(AmbulanceEncounterMn) | Context of the Composition |
| date | SΣI | 1..1 | dateTime | Composition editing time |
| author | ΣI | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
| title | ΣI | 1..1 | string | Human Readable name/title |
| section | I | 12..* | (Slice Definition) | Composition is broken into sections Slice: Unordered, Open by value:title |
| section:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section Nested Section | |
| section:anamnesis | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
| extension:anamnesis-giver | I | 0..* | Extension | Extension |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..0 | ||
| url | 1..1 | uri | "anamnesis-giver" | |
| value[x] | I | 0..1 | Reference(PractitionerRoleMn | Related person) | Value of extension |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Anamnesis |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:pain-anamnesis | SI | 0..1 | Reference(Pain anamnesis) | A reference to data that supports this section |
| entry:history-of-illness | SI | 0..1 | Reference(HistoryOfPresentIllness) | A reference to data that supports this section |
| entry:blood-type | SI | 0..1 | Reference(BloodType-mn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | (Slice Definition) | Unknown reference to #Composition.section:anamnesis Nested Section Slice: Unordered, Open by value:title |
| section:female-reproductive-system-anamnesis | I | 0..1 | BackboneElement | Nested Section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Female reproductive system anamnesis |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:last-menstrual-period | SI | 0..1 | Reference(LastMenstrualPeriod) | A reference to data that supports this section |
| entry:pregnancy-status | SI | 0..1 | Reference(PregnancyStatus) | A reference to data that supports this section |
| entry:pregnancy-week | SI | 0..1 | Reference(PregnancyWeek) | A reference to data that supports this section |
| entry:menopause | SI | 0..1 | Reference(MenopauseStatus) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:anamnesis Nested Section | |
| section:epidemiological-anamnesis | I | 0..1 | BackboneElement | Nested Section |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Epidemiological anamnesis |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:contact-skin-rash | SI | 0..1 | Reference(Resource) | A reference to data that supports this section |
| entry:travelled-abroad | SI | 0..1 | Reference(Resource) | A reference to data that supports this section |
| entry:contact-infectious-disease | SI | 0..1 | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:anamnesis Nested Section | |
| section:adverse-reaction | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 0..1 | string | Label for section (e.g. for ToC) |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:adverse-reaction Nested Section | |
| section:allergies | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Allergy and adverse reaction |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(AllergyIntoleranceMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:allergies Nested Section | |
| section:first-visit | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: First visit |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(FirstVisitMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:first-visit Nested Section | |
| section:vital-sign | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital sign |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(VitalSignsMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:vital-sign Nested Section | |
| section:triage | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Triage |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | SI | 0..* | Reference(TriageMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:triage Nested Section | |
| section:treatment-plan | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Treatment plan |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(ServiceRequest) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:treatment-plan Nested Section | |
| section:physicians-note | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | SI | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Progress note/Physician note |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(ProgressNoteMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:physicians-note Nested Section | |
| section:imaging-test-study | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Imaging test study result |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(ImagingReportMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:imaging-test-study Nested Section | |
| section:laboratory-test-study | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Laboratory test study result |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(LabReportMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:laboratory-test-study Nested Section | |
| section:medication-prescription | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Medication prescription |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(MedicationRequestMn) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:medication-prescription Nested Section | |
| section:advice-to-patient | SI | 1..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | I | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Recommendation to a patient |
| code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
| focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred) |
| entry | I | 0..* | Reference(Communication) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition.section:advice-to-patient Nested Section | |
| Documentation for this format | ||||
Other representations of profile: Schematron
| Path | Conformance | ValueSet / Code |
| Composition.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | Pattern: LOINC code 15507-7("Emergency department Progress note") |
| Composition.category | example | DocumentClassValueSet |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.relatesTo.code | required | DocumentRelationshipType |
| Composition.event.code | example | v3.ActCode |
| Composition.section.code | example | DocumentSectionCodes |
| Composition.section.mode | required | ListMode |
| Composition.section.orderedBy | preferred | ListOrderCodes |
| Composition.section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:anamnesis.code | example | DocumentSectionCodes |
| Composition.section:anamnesis.mode | required | ListMode |
| Composition.section:anamnesis.orderedBy | preferred | ListOrderCodes |
| Composition.section:anamnesis.emptyReason | preferred | ListEmptyReasons |
| Composition.section:anamnesis.section:female-reproductive-system-anamnesis.code | example | DocumentSectionCodes |
| Composition.section:anamnesis.section:female-reproductive-system-anamnesis.mode | required | ListMode |
| Composition.section:anamnesis.section:female-reproductive-system-anamnesis.orderedBy | preferred | ListOrderCodes |
| Composition.section:anamnesis.section:female-reproductive-system-anamnesis.emptyReason | preferred | ListEmptyReasons |
| Composition.section:anamnesis.section:epidemiological-anamnesis.code | example | DocumentSectionCodes |
| Composition.section:anamnesis.section:epidemiological-anamnesis.mode | required | ListMode |
| Composition.section:anamnesis.section:epidemiological-anamnesis.orderedBy | preferred | ListOrderCodes |
| Composition.section:anamnesis.section:epidemiological-anamnesis.emptyReason | preferred | ListEmptyReasons |
| Composition.section:adverse-reaction.code | example | DocumentSectionCodes |
| Composition.section:adverse-reaction.mode | required | ListMode |
| Composition.section:adverse-reaction.orderedBy | preferred | ListOrderCodes |
| Composition.section:adverse-reaction.emptyReason | preferred | ListEmptyReasons |
| Composition.section:allergies.code | example | DocumentSectionCodes |
| Composition.section:allergies.mode | required | ListMode |
| Composition.section:allergies.orderedBy | preferred | ListOrderCodes |
| Composition.section:allergies.emptyReason | preferred | ListEmptyReasons |
| Composition.section:first-visit.code | example | DocumentSectionCodes |
| Composition.section:first-visit.mode | required | ListMode |
| Composition.section:first-visit.orderedBy | preferred | ListOrderCodes |
| Composition.section:first-visit.emptyReason | preferred | ListEmptyReasons |
| Composition.section:vital-sign.code | example | DocumentSectionCodes |
| Composition.section:vital-sign.mode | required | ListMode |
| Composition.section:vital-sign.orderedBy | preferred | ListOrderCodes |
| Composition.section:vital-sign.emptyReason | preferred | ListEmptyReasons |
| Composition.section:triage.code | example | DocumentSectionCodes |
| Composition.section:triage.mode | required | ListMode |
| Composition.section:triage.orderedBy | preferred | ListOrderCodes |
| Composition.section:triage.emptyReason | preferred | ListEmptyReasons |
| Composition.section:treatment-plan.code | example | DocumentSectionCodes |
| Composition.section:treatment-plan.mode | required | ListMode |
| Composition.section:treatment-plan.orderedBy | preferred | ListOrderCodes |
| Composition.section:treatment-plan.emptyReason | preferred | ListEmptyReasons |
| Composition.section:physicians-note.code | example | DocumentSectionCodes |
| Composition.section:physicians-note.mode | required | ListMode |
| Composition.section:physicians-note.orderedBy | preferred | ListOrderCodes |
| Composition.section:physicians-note.emptyReason | preferred | ListEmptyReasons |
| Composition.section:imaging-test-study.code | example | DocumentSectionCodes |
| Composition.section:imaging-test-study.mode | required | ListMode |
| Composition.section:imaging-test-study.orderedBy | preferred | ListOrderCodes |
| Composition.section:imaging-test-study.emptyReason | preferred | ListEmptyReasons |
| Composition.section:laboratory-test-study.code | example | DocumentSectionCodes |
| Composition.section:laboratory-test-study.mode | required | ListMode |
| Composition.section:laboratory-test-study.orderedBy | preferred | ListOrderCodes |
| Composition.section:laboratory-test-study.emptyReason | preferred | ListEmptyReasons |
| Composition.section:medication-prescription.code | example | DocumentSectionCodes |
| Composition.section:medication-prescription.mode | required | ListMode |
| Composition.section:medication-prescription.orderedBy | preferred | ListOrderCodes |
| Composition.section:medication-prescription.emptyReason | preferred | ListEmptyReasons |
| Composition.section:advice-to-patient.code | example | DocumentSectionCodes |
| Composition.section:advice-to-patient.mode | required | ListMode |
| Composition.section:advice-to-patient.orderedBy | preferred | ListOrderCodes |
| Composition.section:advice-to-patient.emptyReason | preferred | ListEmptyReasons |
| Id | Path | Details | Requirements |