Publish Box goes here
SD.42 StructureDefinition-Composition-hcer-uv-trillium2
Conformance resource variables defined here
SD.42.1 Formal Views of Profile Content
Description of Profiles, Differentials, and Snapshots.
The official URL for this profile is: http://hl7.eu/fhir/trillium2/StructureDefinition/Composition-hcer-uv-trillium2
Published on Mon Mar 11 00:00:00 CET 2019 as a draft by Trillium2 Project.
This profile builds on Clinical Document Profile for Composition
Summary
Mandatory: 17 elements (62 nested mandatory elements)
Must-Support: 148 elements
Fixed Value: 22 elements
Prohibited: 39 elements
Structures
This structure refers to these other structures:
- http://hl7.org/fhir/uv/ips/StructureDefinition/Coding-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Patient-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Encounter-uv-trillium2
- http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/MedicationStatement-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/AllergyIntolerance-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Condition-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Procedure-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Immunization-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/DeviceUseStatement-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-laboratory-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-imaging-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-pathology-uv-ips
- http://hl7.org/fhir/StructureDefinition/vitalsigns
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-tobaccouse-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-alcoholuse-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-pregnancy-status-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-pregnancy-outcome-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/MedicationAdministration-uv-trillium2
Slices
This structure defines the following Slices:
- The element Composition.section is sliced based on the value of value:code
- The element Composition.section.entry is sliced based on the value of profile:resolve() (Open at End)
- The element Composition.section.entry is sliced based on the value of profile:resolve()
Differential View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | S | 0..* | Encounter Report composition | |
id | S | 0..1 | id | |
meta | S | 0..1 | Meta | |
text | S | 0..1 | Narrative | |
identifier | S | 0..1 | Identifier | |
status | S | 1..1 | code | |
type | S | 1..1 | CodeableConcept | Kind of composition ("Patient Summary") |
coding | S | 1..* | CodingIPS | Code identifying the Encounter Report |
system | S | 1..1 | uri | Fixed Value: http://loinc.org |
code | S | 1..1 | code | Fixed Value: 34133-9 |
subject | S | 1..1 | Reference(Patient (Trillium II)) | |
reference | S | 1..1 | string | |
encounter | S | 0..1 | Reference(Encounter (Trillium II)) | |
reference | S | 1..1 | string | |
date | S | 1..1 | dateTime | |
author | S | 1..* | Reference(Practitioner | Device | Patient | RelatedPerson) | Who and/or what authored the Encounter Report |
reference | S | 0..1 | string | |
title | S | 1..1 | string | International Patient Summary |
confidentiality | S | 0..1 | code | |
attester | S | 0..* | BackboneElement | |
mode | S | 1..* | code | |
time | S | 0..1 | dateTime | |
party | S | 0..1 | Reference(Patient | Practitioner | Organization) | |
reference | S | 0..1 | string | |
custodian | S | 0..1 | Reference(Organization) | |
reference | S | 0..1 | string | |
relatesTo | S | 0..* | BackboneElement | |
code | S | 1..1 | code | |
target[x] | S | 1..1 | Identifier, Reference(Composition | Trillium II IPS) | |
section | S | BackboneElement | Sections composing the HCER Slice: Unordered, Open by value:code | |
section | S | 1..1 | BackboneElement | HCER Medication Summary Section |
title | S | 1..1 | string | Medication Summary section |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]} (History of Medication use Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Medications relevant for the scope of the patient summary Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Medication Statement (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 1..1 | BackboneElement | HCER Allergies and Intolerances Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]} (Allergies and adverse reactions Document) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Allergy Intolerance (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | HCER Problems Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]} (Problem list - Reported) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Condition (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | HCER History of Procedures Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"47519-4"}]} (History of Procedures Document) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Procedure (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | HCER Immunizations Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"11369-6"}]} (History of Immunization Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Patient's immunization status and pertinent history. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Immunization (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | HCER Medical Devices Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"46264-8"}]} (History of medical device use) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Patient history of medical device use. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Device Use Statement (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS Results Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]} (Relevant diagnostic tests/laboratory data Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..* | Reference(Observation (Results: generic)) | |
entry | S | 0..* | Reference(Observation (Results: laboratory)) | |
entry | S | 0..* | Reference(Observation (Results: imaging)) | |
entry | S | 0..* | Reference(Observation (Results: pathology)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS Vital Signs Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]} (Vital signs) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Notable vital signs or physical findings. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..* | Reference(VitalSigns) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | HCER History of Past Illness Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"11348-0"}]} (History of Past illness Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Conditions the patient suffered in the past. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Condition (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS Functional Status |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"47420-5"}]} (Functional status assessment note) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Optional entry used to represent disabilities and functional assessments Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..* | Reference(Condition (Trillium II)) | |
entry | S | 0..* | Reference(ClinicalImpression) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS Plan of Care Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]} (Plan of care note) |
text | S | 1..1 | Narrative | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | HCER Social History Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"29762-2"}]} (Social history Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..1 | Reference(Observation (SH: tobacco use)) | |
entry | S | 0..1 | Reference(Observation (SH: alcohol use)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS History of Pregnancy Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"10162-6"}]} (History of pregnancies Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..* | Reference(Observation (Pregnancy: status)) | |
entry | S | 0..* | Reference(Observation (Pregnancy: outcome)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS Advance Directives Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"42348-3"}]} (Advance directives) |
text | S | 1..1 | Narrative | |
entry | S | 0..* | Reference(Resource | Consent) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | Encounters sections |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConcept | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"46240-8"}]} (History of Hospitalizations+Outpatient visits Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..* | Reference(Encounter (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | Admission Medications |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"42346-7"}]} (Medications on admission (narrative)) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..* | Reference(Medication Statement (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | Hospital course |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"8648-8"}]} (Hospital course Narrative) |
text | S | 1..1 | Narrative | |
section | 0..0 | |||
section | S | 0..1 | BackboneElement | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"29554-3"}]} (Procedure Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..* | Reference(Procedure (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | Admission Medications |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"29549-3"}]} (Medication administered Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..* | Reference(Medication Administration (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | Admission Medications |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"42346-7"}]} (Medications on admission (narrative)) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Slice: Unordered, Open by profile:resolve() | |
entry | S | 0..* | Reference(Medication Statement (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | SI | 0..* | Encounter Report composition | |
id | SΣ | 0..1 | id | Logical id of this artifact |
meta | SΣ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: Common Languages (extensible) Max Binding: All Languages | |
text | SI | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | SΣ | 0..1 | Identifier | Logical identifier of composition (version-independent) |
status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required) |
type | SΣ | 1..1 | CodeableConcept | Kind of composition ("Patient Summary") Binding: FHIR Document Type Codes (preferred) |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
coding | SI | 1..* | CodingIPS | Code identifying the Encounter Report |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
version | SΣ | 0..1 | string | Version of the system - if relevant |
code | SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 34133-9 |
display | SΣ | 0..1 | string | Representation defined by the system |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
translation | SI | 0..* | (Complex) | Language Translation (Localization) URL: http://hl7.org/fhir/StructureDefinition/translation |
value | 0..1 | Primitive value for string Max Length: 1048576 | ||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
text | Σ | 0..1 | string | Plain text representation of the concept |
class | Σ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
subject | SΣ | 1..1 | Reference(Patient (Trillium II)) | Who and/or what the composition is about |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
reference | SΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
display | Σ | 0..1 | string | Text alternative for the resource |
encounter | SΣ | 0..1 | Reference(Encounter (Trillium II)) | Context of the Composition |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
reference | SΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
display | Σ | 0..1 | string | Text alternative for the resource |
date | SΣ | 1..1 | dateTime | Composition editing time |
author | SΣ | 1..* | Reference(Practitioner | Device | Patient | RelatedPerson) | Who and/or what authored the Encounter Report |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
reference | SΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
display | Σ | 0..1 | string | Text alternative for the resource |
title | SΣ | 1..1 | string | International Patient Summary |
confidentiality | ?!SΣ | 0..1 | code | As defined by affinity domain Binding: ConfidentialityClassification (required) |
attester | SΣI | 0..* | BackboneElement | Attests to accuracy of composition |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
mode | SΣ | 1..* | code | personal | professional | legal | official Binding: CompositionAttestationMode (required) |
time | SΣ | 0..1 | dateTime | When the composition was attested |
party | SΣ | 0..1 | Reference(Patient | Practitioner | Organization) | Who attested the composition |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
reference | SΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
display | Σ | 0..1 | string | Text alternative for the resource |
custodian | SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
reference | SΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
display | Σ | 0..1 | string | Text alternative for the resource |
relatesTo | SΣI | 0..* | BackboneElement | Relationships to other compositions/documents |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
code | SΣ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required) |
target[x] | SΣ | 1..1 | Identifier, Reference(Composition | Trillium II IPS) | Target of the relationship |
event | ΣI | 0..* | BackboneElement | The clinical service(s) being documented |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: ActCode (example) |
period | Σ | 0..1 | Period | The period covered by the documentation |
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
section | SI | BackboneElement | Sections composing the HCER Slice: Unordered, Open by value:code | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 0..1 | string | Label for section (e.g. for ToC) | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Document Section Codes (example) | |
text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (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: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section Nested Section | |
section | SI | 1..1 | BackboneElement | HCER Medication Summary Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Medication Summary section |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]} (History of Medication use Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Medications relevant for the scope of the patient summary Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Medication Statement (Trillium II)) | A reference to data that supports this section |
section | SI | 1..1 | BackboneElement | HCER Allergies and Intolerances Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]} (Allergies and adverse reactions Document) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Allergy Intolerance (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | HCER Problems Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]} (Problem list - Reported) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Condition (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | HCER History of Procedures Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"47519-4"}]} (History of Procedures Document) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Procedure (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | HCER Immunizations Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"11369-6"}]} (History of Immunization Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Patient's immunization status and pertinent history. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Immunization (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | HCER Medical Devices Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"46264-8"}]} (History of medical device use) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Patient history of medical device use. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Device Use Statement (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS Results Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]} (Relevant diagnostic tests/laboratory data Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..* | Reference(Observation (Results: generic)) | A reference to data that supports this section |
entry | SI | 0..* | Reference(Observation (Results: laboratory)) | A reference to data that supports this section |
entry | SI | 0..* | Reference(Observation (Results: imaging)) | A reference to data that supports this section |
entry | SI | 0..* | Reference(Observation (Results: pathology)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS Vital Signs Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]} (Vital signs) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Notable vital signs or physical findings. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..* | Reference(VitalSigns) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | HCER History of Past Illness Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"11348-0"}]} (History of Past illness Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Conditions the patient suffered in the past. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Condition (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS Functional Status |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"47420-5"}]} (Functional status assessment note) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Optional entry used to represent disabilities and functional assessments Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..* | Reference(Condition (Trillium II)) | A reference to data that supports this section |
entry | SI | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS Plan of Care Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]} (Plan of care note) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | HCER Social History Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"29762-2"}]} (Social history Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..1 | Reference(Observation (SH: tobacco use)) | A reference to data that supports this section |
entry | SI | 0..1 | Reference(Observation (SH: alcohol use)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS History of Pregnancy Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"10162-6"}]} (History of pregnancies Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..* | Reference(Observation (Pregnancy: status)) | A reference to data that supports this section |
entry | SI | 0..* | Reference(Observation (Pregnancy: outcome)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS Advance Directives Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"42348-3"}]} (Advance directives) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | 0..* | Reference(Resource | Consent) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | Encounters sections |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"46240-8"}]} (History of Hospitalizations+Outpatient visits Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..* | Reference(Encounter (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | Admission Medications |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"42346-7"}]} (Medications on admission (narrative)) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..* | Reference(Medication Statement (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | Hospital course |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 0..1 | string | Label for section (e.g. for ToC) | |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"8648-8"}]} (Hospital course Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (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: List Empty Reasons (preferred) |
section | SI | 0..1 | BackboneElement | Composition is broken into sections |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 0..1 | string | Label for section (e.g. for ToC) | |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"29554-3"}]} (Procedure Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..* | Reference(Procedure (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | Admission Medications |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"29549-3"}]} (Medication administered Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..* | Reference(Medication Administration (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | Admission Medications |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"42346-7"}]} (Medications on admission (narrative)) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
entry | SI | 0..* | Reference(Medication Statement (Trillium II)) | A reference to data that supports this section |
Documentation for this format |
Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron