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
The Outpatient care summary represents an encounter with a medical professional which does not involve hospitalization. This document details examination, findings, treatment decisions and plan of treatment for the patient.
The official URL for this profile is:
http://fhir.mn/StructureDefinition/mng-outpatient-care-summary
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
Summary
Mandatory: 5 elements (17 nested mandatory elements)
Must-Support: 48 elements
Fixed Value: 1 element
Prohibited: 2 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 | |
  subject | S | 1..1 | Reference(PatientMn) | Who and/or what the composition is about |
| encounter | S | 1..1 | Reference(OutpatientEncounterMn) | Context of the Composition |
| author | S | 1..* | Reference(PractitionerRoleMn) | Who and/or what authored the composition |
 confidentiality | S | 0..0 | ||
  section | 1..* | (Slice Definition) | Composition is broken into sections Slice: Unordered, Closed 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 | S | 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:medical-history | S | 0..* | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Past medical history / Өмнөх өвчлөлийн түүх |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) 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: 11348-0 | |
| entry | 0..* | Reference(DiseaseMn) | A reference to data that supports this section | |
| section:social-history | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Social history / Үйлчлүүлэгчийн хорт зуршил хэрэглэдэг эсэх талаарх мэдээлэл |
| entry | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:smoking | S | 0..1 | Reference(SmokingMn) | A reference to data that supports this section |
| entry:alcohol-use | S | 0..1 | Reference(AlcoholHistoryMn) | A reference to data that supports this section |
| entry:drug-use | S | 0..1 | Reference(DrugUseHistoryMn) | A reference to data that supports this section |
| section:family-history | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Family history / Үйлчлүүлэгчийн гэр бүлийн гишүүд, ойр дотны хүмүүсийн өвчлөлийн талаарх мэдээлэл |
| entry | 0..* | Reference(FamilyMemberHistoryMn) | A reference to data that supports this section | |
| section:medical-devices | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Medical devices / Суулгацын талаарх мэдээлэл |
| entry | 0..* | Reference(DeviceUseStatementMn) | A reference to data that supports this section | |
| section:medication-history | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Medication history / Үйлчлүүлэгчийн хэрэглэж байгаа эмийн талаарх мэдээлэл |
| entry | 0..* | Reference(MedicationStatementMn) | A reference to data that supports this section | |
| section:allergy-adverse-reaction | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Allergy and adverse reaction / Үйлчлүүлэгчийн хэрэглэж байгаа эмийн талаарх мэдээлэл |
| entry | 0..* | Reference(AllergyIntoleranceMn) | A reference to data that supports this section | |
| section:vital-signs | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs / Амин үзүүлэлт |
| entry | 0..* | Reference(VitalSignsMn) | A reference to data that supports this section | |
| section:progress-note | S | 0..* | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Progress note / Эмчийн үзлэгийн тэмдэглэл |
| entry | 0..* | Reference(PhysicalExamNote) | A reference to data that supports this section | |
| section:diagnostic-tests | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Treatment plan / Үйлчлүүлэгчийн эмчилгээ, оношилгооны төлөвлөгөө |
| entry | 0..* | Reference(LabReferralMn | ImagingReferralMn | ElectronicReferralMn) | A reference to data that supports this section | |
| section:surgery | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Performed procedure and intervention / Хийгдсэн мэс засал, мэс ажилбар |
| entry | 0..* | Reference(Surgical Procedure) | A reference to data that supports this section | |
| section:imaging-test-study | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Imaging Study Results / Дүрс оношилгооны шинжилгээний үр дүн |
| entry | 0..* | Reference(ImagingReportMn) | A reference to data that supports this section | |
| section:laboratory-test-study | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Laboratory test results / Лабораторын шинжилгээний үр дүнгүүд |
| entry | 0..* | Reference(LabReportMn) | A reference to data that supports this section | |
| section:prescription | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Prescription / Эмийн жор |
| entry | 0..* | Reference(MedicationRequestMn) | A reference to data that supports this section | |
| section:other-documentation | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Attached Special Records / Хавсаргасан тусгай файлууд |
| entry | 0..* | Reference(AttachedSpecialRecord) | 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) |
| 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(OutpatientEncounterMn) | Context of the Composition |
| date | ΣI | 1..1 | dateTime | Composition editing time |
| author | SΣI | 1..* | Reference(PractitionerRoleMn) | Who and/or what authored the composition |
| title | ΣI | 1..1 | string | Human Readable name/title |
 attester | I | 0..* | BackboneElement | Attests to accuracy of composition |
 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 |
| mode | I | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required) |
| time | I | 0..1 | dateTime | When the composition was attested |
| party | I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
| custodian | ΣI | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo | I | 0..* | BackboneElement | Relationships to other compositions/documents |
| 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 |
| code | I | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required) |
 target[x] | I | 1..1 | Target of the relationship | |
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition) | |||
| event | ΣI | 0..* | BackboneElement | The clinical service(s) being documented |
| 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 |
| code | ΣI | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
| period | ΣI | 0..1 | Period | The period covered by the documentation |
| detail | ΣI | 0..* | Reference(Resource) | The event(s) being documented |
| section | I | 1..* | (Slice Definition) | Composition is broken into sections Slice: Unordered, Closed 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 | SI | 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:medical-history | SI | 0..* | 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: Past medical history / Өмнөх өвчлөлийн түүх |
| code | SI | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) 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 | 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(DiseaseMn) | 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:medical-history Nested Section | |
| section:social-history | SI | 0..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: Social history / Үйлчлүүлэгчийн хорт зуршил хэрэглэдэг эсэх талаарх мэдээлэл |
| 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:smoking | SI | 0..1 | Reference(SmokingMn) | A reference to data that supports this section |
| entry:alcohol-use | SI | 0..1 | Reference(AlcoholHistoryMn) | A reference to data that supports this section |
| entry:drug-use | SI | 0..1 | Reference(DrugUseHistoryMn) | 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:social-history Nested Section | |
| section:family-history | SI | 0..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: Family history / Үйлчлүүлэгчийн гэр бүлийн гишүүд, ойр дотны хүмүүсийн өвчлөлийн талаарх мэдээлэл |
| 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(FamilyMemberHistoryMn) | 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:family-history Nested Section | |
| section:medical-devices | SI | 0..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: Medical devices / Суулгацын талаарх мэдээлэл |
| 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(DeviceUseStatementMn) | 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:medical-devices Nested Section | |
| section:medication-history | SI | 0..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: Medication history / Үйлчлүүлэгчийн хэрэглэж байгаа эмийн талаарх мэдээлэл |
| 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(MedicationStatementMn) | 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-history Nested Section | |
| section:allergy-adverse-reaction | SI | 0..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: Allergy and adverse reaction / Үйлчлүүлэгчийн хэрэглэж байгаа эмийн талаарх мэдээлэл |
| 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(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:allergy-adverse-reaction Nested Section | |
| section:vital-signs | SI | 0..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: Vital signs / Амин үзүүлэлт |
| 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(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-signs Nested Section | |
| section:progress-note | SI | 0..* | 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 / Эмчийн үзлэгийн тэмдэглэл |
| 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(PhysicalExamNote) | 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:progress-note Nested Section | |
| section:diagnostic-tests | SI | 0..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: Treatment plan / Үйлчлүүлэгчийн эмчилгээ, оношилгооны төлөвлөгөө |
| 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(LabReferralMn | ImagingReferralMn | ElectronicReferralMn) | 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:diagnostic-tests Nested Section | |
| section:surgery | SI | 0..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: Performed procedure and intervention / Хийгдсэн мэс засал, мэс ажилбар |
| 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(Surgical Procedure) | 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:surgery Nested Section | |
| section:imaging-test-study | SI | 0..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: Imaging Study Results / Дүрс оношилгооны шинжилгээний үр дүн |
| 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 | 0..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: Laboratory test results / Лабораторын шинжилгээний үр дүнгүүд |
| 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:prescription | SI | 0..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: Prescription / Эмийн жор |
| 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:prescription Nested Section | |
| section:other-documentation | SI | 0..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: Attached Special Records / Хавсаргасан тусгай файлууд |
| 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(AttachedSpecialRecord) | 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:other-documentation Nested Section | |
| Documentation for this format | ||||
This structure is derived from Composition
Summary
Mandatory: 5 elements (17 nested mandatory elements)
Must-Support: 48 elements
Fixed Value: 1 element
Prohibited: 2 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 | |
| subject | S | 1..1 | Reference(PatientMn) | Who and/or what the composition is about |
| encounter | S | 1..1 | Reference(OutpatientEncounterMn) | Context of the Composition |
| author | S | 1..* | Reference(PractitionerRoleMn) | Who and/or what authored the composition |
| confidentiality | S | 0..0 | ||
| section | 1..* | (Slice Definition) | Composition is broken into sections Slice: Unordered, Closed 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 | S | 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:medical-history | S | 0..* | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Past medical history / Өмнөх өвчлөлийн түүх |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) 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: 11348-0 | |
| entry | 0..* | Reference(DiseaseMn) | A reference to data that supports this section | |
| section:social-history | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Social history / Үйлчлүүлэгчийн хорт зуршил хэрэглэдэг эсэх талаарх мэдээлэл |
| entry | 0..* | (Slice Definition) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:smoking | S | 0..1 | Reference(SmokingMn) | A reference to data that supports this section |
| entry:alcohol-use | S | 0..1 | Reference(AlcoholHistoryMn) | A reference to data that supports this section |
| entry:drug-use | S | 0..1 | Reference(DrugUseHistoryMn) | A reference to data that supports this section |
| section:family-history | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Family history / Үйлчлүүлэгчийн гэр бүлийн гишүүд, ойр дотны хүмүүсийн өвчлөлийн талаарх мэдээлэл |
| entry | 0..* | Reference(FamilyMemberHistoryMn) | A reference to data that supports this section | |
| section:medical-devices | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Medical devices / Суулгацын талаарх мэдээлэл |
| entry | 0..* | Reference(DeviceUseStatementMn) | A reference to data that supports this section | |
| section:medication-history | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Medication history / Үйлчлүүлэгчийн хэрэглэж байгаа эмийн талаарх мэдээлэл |
| entry | 0..* | Reference(MedicationStatementMn) | A reference to data that supports this section | |
| section:allergy-adverse-reaction | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Allergy and adverse reaction / Үйлчлүүлэгчийн хэрэглэж байгаа эмийн талаарх мэдээлэл |
| entry | 0..* | Reference(AllergyIntoleranceMn) | A reference to data that supports this section | |
| section:vital-signs | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Vital signs / Амин үзүүлэлт |
| entry | 0..* | Reference(VitalSignsMn) | A reference to data that supports this section | |
| section:progress-note | S | 0..* | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Progress note / Эмчийн үзлэгийн тэмдэглэл |
| entry | 0..* | Reference(PhysicalExamNote) | A reference to data that supports this section | |
| section:diagnostic-tests | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Treatment plan / Үйлчлүүлэгчийн эмчилгээ, оношилгооны төлөвлөгөө |
| entry | 0..* | Reference(LabReferralMn | ImagingReferralMn | ElectronicReferralMn) | A reference to data that supports this section | |
| section:surgery | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Performed procedure and intervention / Хийгдсэн мэс засал, мэс ажилбар |
| entry | 0..* | Reference(Surgical Procedure) | A reference to data that supports this section | |
| section:imaging-test-study | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Imaging Study Results / Дүрс оношилгооны шинжилгээний үр дүн |
| entry | 0..* | Reference(ImagingReportMn) | A reference to data that supports this section | |
| section:laboratory-test-study | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Laboratory test results / Лабораторын шинжилгээний үр дүнгүүд |
| entry | 0..* | Reference(LabReportMn) | A reference to data that supports this section | |
| section:prescription | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Prescription / Эмийн жор |
| entry | 0..* | Reference(MedicationRequestMn) | A reference to data that supports this section | |
| section:other-documentation | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) Required Pattern: Attached Special Records / Хавсаргасан тусгай файлууд |
| entry | 0..* | Reference(AttachedSpecialRecord) | 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) |
| 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(OutpatientEncounterMn) | Context of the Composition |
| date | ΣI | 1..1 | dateTime | Composition editing time |
| author | SΣI | 1..* | Reference(PractitionerRoleMn) | Who and/or what authored the composition |
| title | ΣI | 1..1 | string | Human Readable name/title |
| attester | I | 0..* | BackboneElement | Attests to accuracy of composition |
| 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 |
| mode | I | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required) |
| time | I | 0..1 | dateTime | When the composition was attested |
| party | I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
| custodian | ΣI | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo | I | 0..* | BackboneElement | Relationships to other compositions/documents |
| 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 |
| code | I | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required) |
| target[x] | I | 1..1 | Target of the relationship | |
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition) | |||
| event | ΣI | 0..* | BackboneElement | The clinical service(s) being documented |
| 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 |
| code | ΣI | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
| period | ΣI | 0..1 | Period | The period covered by the documentation |
| detail | ΣI | 0..* | Reference(Resource) | The event(s) being documented |
| section | I | 1..* | (Slice Definition) | Composition is broken into sections Slice: Unordered, Closed 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 | SI | 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:medical-history | SI | 0..* | 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: Past medical history / Өмнөх өвчлөлийн түүх |
| code | SI | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) 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 | 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(DiseaseMn) | 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:medical-history Nested Section | |
| section:social-history | SI | 0..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: Social history / Үйлчлүүлэгчийн хорт зуршил хэрэглэдэг эсэх талаарх мэдээлэл |
| 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:smoking | SI | 0..1 | Reference(SmokingMn) | A reference to data that supports this section |
| entry:alcohol-use | SI | 0..1 | Reference(AlcoholHistoryMn) | A reference to data that supports this section |
| entry:drug-use | SI | 0..1 | Reference(DrugUseHistoryMn) | 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:social-history Nested Section | |
| section:family-history | SI | 0..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: Family history / Үйлчлүүлэгчийн гэр бүлийн гишүүд, ойр дотны хүмүүсийн өвчлөлийн талаарх мэдээлэл |
| 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(FamilyMemberHistoryMn) | 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:family-history Nested Section | |
| section:medical-devices | SI | 0..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: Medical devices / Суулгацын талаарх мэдээлэл |
| 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(DeviceUseStatementMn) | 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:medical-devices Nested Section | |
| section:medication-history | SI | 0..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: Medication history / Үйлчлүүлэгчийн хэрэглэж байгаа эмийн талаарх мэдээлэл |
| 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(MedicationStatementMn) | 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-history Nested Section | |
| section:allergy-adverse-reaction | SI | 0..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: Allergy and adverse reaction / Үйлчлүүлэгчийн хэрэглэж байгаа эмийн талаарх мэдээлэл |
| 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(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:allergy-adverse-reaction Nested Section | |
| section:vital-signs | SI | 0..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: Vital signs / Амин үзүүлэлт |
| 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(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-signs Nested Section | |
| section:progress-note | SI | 0..* | 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 / Эмчийн үзлэгийн тэмдэглэл |
| 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(PhysicalExamNote) | 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:progress-note Nested Section | |
| section:diagnostic-tests | SI | 0..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: Treatment plan / Үйлчлүүлэгчийн эмчилгээ, оношилгооны төлөвлөгөө |
| 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(LabReferralMn | ImagingReferralMn | ElectronicReferralMn) | 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:diagnostic-tests Nested Section | |
| section:surgery | SI | 0..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: Performed procedure and intervention / Хийгдсэн мэс засал, мэс ажилбар |
| 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(Surgical Procedure) | 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:surgery Nested Section | |
| section:imaging-test-study | SI | 0..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: Imaging Study Results / Дүрс оношилгооны шинжилгээний үр дүн |
| 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 | 0..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: Laboratory test results / Лабораторын шинжилгээний үр дүнгүүд |
| 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:prescription | SI | 0..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: Prescription / Эмийн жор |
| 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:prescription Nested Section | |
| section:other-documentation | SI | 0..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: Attached Special Records / Хавсаргасан тусгай файлууд |
| 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(AttachedSpecialRecord) | 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:other-documentation 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 | FHIRDocumentTypeCodes |
| 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:medical-history.code | example | Pattern: LOINC code 11348-0 |
| Composition.section:medical-history.mode | required | ListMode |
| Composition.section:medical-history.orderedBy | preferred | ListOrderCodes |
| Composition.section:medical-history.emptyReason | preferred | ListEmptyReasons |
| Composition.section:social-history.code | example | DocumentSectionCodes |
| Composition.section:social-history.mode | required | ListMode |
| Composition.section:social-history.orderedBy | preferred | ListOrderCodes |
| Composition.section:social-history.emptyReason | preferred | ListEmptyReasons |
| Composition.section:family-history.code | example | DocumentSectionCodes |
| Composition.section:family-history.mode | required | ListMode |
| Composition.section:family-history.orderedBy | preferred | ListOrderCodes |
| Composition.section:family-history.emptyReason | preferred | ListEmptyReasons |
| Composition.section:medical-devices.code | example | DocumentSectionCodes |
| Composition.section:medical-devices.mode | required | ListMode |
| Composition.section:medical-devices.orderedBy | preferred | ListOrderCodes |
| Composition.section:medical-devices.emptyReason | preferred | ListEmptyReasons |
| Composition.section:medication-history.code | example | DocumentSectionCodes |
| Composition.section:medication-history.mode | required | ListMode |
| Composition.section:medication-history.orderedBy | preferred | ListOrderCodes |
| Composition.section:medication-history.emptyReason | preferred | ListEmptyReasons |
| Composition.section:allergy-adverse-reaction.code | example | DocumentSectionCodes |
| Composition.section:allergy-adverse-reaction.mode | required | ListMode |
| Composition.section:allergy-adverse-reaction.orderedBy | preferred | ListOrderCodes |
| Composition.section:allergy-adverse-reaction.emptyReason | preferred | ListEmptyReasons |
| Composition.section:vital-signs.code | example | DocumentSectionCodes |
| Composition.section:vital-signs.mode | required | ListMode |
| Composition.section:vital-signs.orderedBy | preferred | ListOrderCodes |
| Composition.section:vital-signs.emptyReason | preferred | ListEmptyReasons |
| Composition.section:progress-note.code | example | DocumentSectionCodes |
| Composition.section:progress-note.mode | required | ListMode |
| Composition.section:progress-note.orderedBy | preferred | ListOrderCodes |
| Composition.section:progress-note.emptyReason | preferred | ListEmptyReasons |
| Composition.section:diagnostic-tests.code | example | DocumentSectionCodes |
| Composition.section:diagnostic-tests.mode | required | ListMode |
| Composition.section:diagnostic-tests.orderedBy | preferred | ListOrderCodes |
| Composition.section:diagnostic-tests.emptyReason | preferred | ListEmptyReasons |
| Composition.section:surgery.code | example | DocumentSectionCodes |
| Composition.section:surgery.mode | required | ListMode |
| Composition.section:surgery.orderedBy | preferred | ListOrderCodes |
| Composition.section:surgery.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:prescription.code | example | DocumentSectionCodes |
| Composition.section:prescription.mode | required | ListMode |
| Composition.section:prescription.orderedBy | preferred | ListOrderCodes |
| Composition.section:prescription.emptyReason | preferred | ListEmptyReasons |
| Composition.section:other-documentation.code | example | DocumentSectionCodes |
| Composition.section:other-documentation.mode | required | ListMode |
| Composition.section:other-documentation.orderedBy | preferred | ListOrderCodes |
| Composition.section:other-documentation.emptyReason | preferred | ListEmptyReasons |
| Id | Path | Details | Requirements |