This page is part of the C-CDA on FHIR Implementation Guide (v1.0.0: STU 1) based on FHIR R3. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions
{ "resourceType" : "StructureDefinition", "id" : "CCDA-on-FHIR-Progress-Note", "meta" : { "lastUpdated" : "2017-08-10T02:36:03.091+10:00" }, "text" : { "status" : "generated", "div" : "<div xmlns="http://www.w3.org/1999/xhtml"><table border="0" cellpadding="0" cellspacing="0" style="border: 0px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top;"><tr style="border: 1px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top;"><th style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/formats.html#table" title="The logical name of the element">Name</a></th><th style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/formats.html#table" title="Information about the use of the element">Flags</a></th><th style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/formats.html#table" title="Minimum and Maximum # of times the the element can appear in the instance">Card.</a></th><th style="width: 100px" class="hierarchy"><a href="http:/hl7.org/fhir/formats.html#table" title="Reference to the type of the element">Type</a></th><th style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/formats.html#table" title="Additional information about the element">Description & Constraints</a><span style="float: right"><a href="http:/hl7.org/fhir/formats.html#table" title="Legend for this format"><img src="http:/hl7.org/fhir/help16.png" alt="doco" style="background-color: inherit"/></a></span></th></tr><tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">Composition</span><a name="Composition"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span><span style="opacity: 0.5">..</span><span style="opacity: 0.4">*</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">type</span><a name="Composition.type"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">1</span><span style="opacity: 0.5">..</span><span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">type<br/><span style="font-weight:bold">Binding: </span><a href="ValueSet-2.16.840.1.113883.11.20.8.1.html">ProgressNoteDocumentTypeCode</a> (<a href="http:/hl7.org/fhir/terminologies.html#required" title="To be conformant, the concept in this element SHALL be from the specified value set">required</a>)</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck12.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_slice.png" alt="." style="background-color: white; background-color: inherit" title="Slice Definition" class="hierarchy"/> <span style="font-style: italic" title="null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4; font-style: italic" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="font-weight:bold; font-style: italic">Slice: </span><span style="font-style: italic">Unordered, Open by value:code</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice assessment_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Assessment Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Assessments<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"51848-0"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck140.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">This section contains only human readable content</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice allergies_and_intolerances_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Allergies and Intolerances Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Allergies, adverse reactions, alerts<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"48765-2"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">text</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck152.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_slice.png" alt="." style="background-color: white; background-color: inherit" title="Slice Definition" class="hierarchy"/> <span style="font-style: italic" title="null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="font-style: italic" href="http:/hl7.org/fhir/references.html">Reference</a><span style="font-style: italic">(</span><a style="opacity: 0.4; font-style: italic" href="http:/hl7.org/fhir/resource.html">Resource</a><span style="font-style: italic">)</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="font-style: italic">entry</span><br style="font-style: italic"/><span style="font-weight:bold; font-style: italic">Slice: </span><span style="font-style: italic">Unordered, Open by profile:reference</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck144.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_reference.png" alt="." style="background-color: white; background-color: inherit" title="Reference to another Resource" class="hierarchy"/> <span title="Slice sliceEntry: null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span><span style="opacity: 0.5">..</span><span style="opacity: 0.4">*</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/references.html">Reference</a>(<a href="http://hl7.org/fhir/us/core//StructureDefinition-us-core-allergyintolerance.html">US Core AllergyIntolerance Profile</a>)</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice assessment_and_plan_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Assessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Assessment and plan<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"51847-2"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">text</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck152.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_slice.png" alt="." style="background-color: white; background-color: inherit" title="Slice Definition" class="hierarchy"/> <span style="font-style: italic" title="null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="font-style: italic" href="http:/hl7.org/fhir/references.html">Reference</a><span style="font-style: italic">(</span><a style="opacity: 0.4; font-style: italic" href="http:/hl7.org/fhir/resource.html">Resource</a><span style="font-style: italic">)</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="font-weight:bold; font-style: italic">Slice: </span><span style="font-style: italic">Unordered, Open by profile:reference</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck144.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_reference.png" alt="." style="background-color: white; background-color: inherit" title="Reference to another Resource" class="hierarchy"/> <span title="Slice sliceEntry: null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span><span style="opacity: 0.5">..</span><span style="opacity: 0.4">*</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/references.html">Reference</a>(<a href="http://hl7.org/fhir/us/core//StructureDefinition-us-core-condition.html">US Core Condition (a.k.a Problem) Profile</a> | <a href="http:/hl7.org/fhir/observation.html">Observation</a> | <a href="http:/hl7.org/fhir/communication.html">Communication</a>)</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. </td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice chief_complaint_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Chief Complaint Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Chief complaint<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"10154-3"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck140.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">This section contains only human readable content</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice instructions_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Instructions Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Instructions<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"69730-0"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck140.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">This section contains only human readable content</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice interventions_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Interventions Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Interventions provided<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"62387-6"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">text</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck152.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_slice.png" alt="." style="background-color: white; background-color: inherit" title="Slice Definition" class="hierarchy"/> <span style="font-style: italic" title="null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="font-style: italic" href="http:/hl7.org/fhir/references.html">Reference</a><span style="font-style: italic">(</span><a style="opacity: 0.4; font-style: italic" href="http:/hl7.org/fhir/resource.html">Resource</a><span style="font-style: italic">)</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="font-style: italic">entry</span><br style="font-style: italic"/><span style="font-weight:bold; font-style: italic">Slice: </span><span style="font-style: italic">Unordered, Open by profile:reference</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck144.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_reference.png" alt="." style="background-color: white; background-color: inherit" title="Reference to another Resource" class="hierarchy"/> <span title="Slice interventions_section_slice: null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span><span style="opacity: 0.5">..</span><span style="opacity: 0.4">*</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/references.html">Reference</a>(<a href="http:/hl7.org/fhir/list.html">List</a> | <a href="http:/hl7.org/fhir/requestgroup.html">RequestGroup</a>)</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. </td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice medications_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Medications Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">History of medication use<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"10160-0"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">text</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck152.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_slice.png" alt="." style="background-color: white; background-color: inherit" title="Slice Definition" class="hierarchy"/> <span style="font-style: italic" title="null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="font-style: italic" href="http:/hl7.org/fhir/references.html">Reference</a><span style="font-style: italic">(</span><a style="opacity: 0.4; font-style: italic" href="http:/hl7.org/fhir/resource.html">Resource</a><span style="font-style: italic">)</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="font-style: italic">entry</span><br style="font-style: italic"/><span style="font-weight:bold; font-style: italic">Slice: </span><span style="font-style: italic">Unordered, Open by profile:reference</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck144.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_reference.png" alt="." style="background-color: white; background-color: inherit" title="Reference to another Resource" class="hierarchy"/> <span title="Slice sliceEntry: null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span><span style="opacity: 0.5">..</span><span style="opacity: 0.4">*</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/references.html">Reference</a>(<a href="http://hl7.org/fhir/us/core//StructureDefinition-us-core-medicationstatement.html">US Core MedicationStatement Profile</a>)</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice nutrition_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Nutrition Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Diet and nutrition<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"61144-2"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">text</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck152.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_slice.png" alt="." style="background-color: white; background-color: inherit" title="Slice Definition" class="hierarchy"/> <span style="font-style: italic" title="null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="font-style: italic" href="http:/hl7.org/fhir/references.html">Reference</a><span style="font-style: italic">(</span><a style="opacity: 0.4; font-style: italic" href="http:/hl7.org/fhir/resource.html">Resource</a><span style="font-style: italic">)</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="font-style: italic">entry</span><br style="font-style: italic"/><span style="font-weight:bold; font-style: italic">Slice: </span><span style="font-style: italic">Unordered, Open by profile:reference</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck144.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_reference.png" alt="." style="background-color: white; background-color: inherit" title="Reference to another Resource" class="hierarchy"/> <span title="Slice sliceEntry: null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span><span style="opacity: 0.5">..</span><span style="opacity: 0.4">*</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/references.html">Reference</a>(<a href="http:/hl7.org/fhir/observation.html">Observation</a>)</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. </td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice objective_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Objective Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Objective<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"61149-1"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck140.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">This section contains only human readable content</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice physical_exam_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Physical Exam Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Physical findings<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"29545-1"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">text</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck152.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_slice.png" alt="." style="background-color: white; background-color: inherit" title="Slice Definition" class="hierarchy"/> <span style="font-style: italic" title="null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="font-style: italic" href="http:/hl7.org/fhir/references.html">Reference</a><span style="font-style: italic">(</span><a style="opacity: 0.4; font-style: italic" href="http:/hl7.org/fhir/resource.html">Resource</a><span style="font-style: italic">)</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="font-style: italic">entry</span><br style="font-style: italic"/><span style="font-weight:bold; font-style: italic">Slice: </span><span style="font-style: italic">Unordered, Open by profile:reference</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck144.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_reference.png" alt="." style="background-color: white; background-color: inherit" title="Reference to another Resource" class="hierarchy"/> <span title="Slice sliceEntry: null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span><span style="opacity: 0.5">..</span><span style="opacity: 0.4">*</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/references.html">Reference</a>(<a href="http:/hl7.org/fhir/observation.html">Observation</a>)</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. </td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice plan_of_treatment_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Plan of Treatment Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Plan of Treatment<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"18776-5"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">text</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck152.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_slice.png" alt="." style="background-color: white; background-color: inherit" title="Slice Definition" class="hierarchy"/> <span style="font-style: italic" title="null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="font-style: italic" href="http:/hl7.org/fhir/references.html">Reference</a><span style="font-style: italic">(</span><a style="opacity: 0.4; font-style: italic" href="http:/hl7.org/fhir/resource.html">Resource</a><span style="font-style: italic">)</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="font-style: italic">entry</span><br style="font-style: italic"/><span style="font-weight:bold; font-style: italic">Slice: </span><span style="font-style: italic">Unordered, Open by profile:reference</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck144.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_reference.png" alt="." style="background-color: white; background-color: inherit" title="Reference to another Resource" class="hierarchy"/> <span title="Slice sliceEntry: null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span><span style="opacity: 0.5">..</span><span style="opacity: 0.4">*</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/references.html">Reference</a>(<a href="http://hl7.org/fhir/us/core//StructureDefinition-us-core-goal.html">US Core Goal Profile</a> | <a href="http://hl7.org/fhir/us/core//StructureDefinition-us-core-medicationrequest.html">US Core MedicationRequest Profile</a> | <a href="http:/hl7.org/fhir/communication.html">Communication</a> | <a href="http:/hl7.org/fhir/appointment.html">Appointment</a> | <a href="http:/hl7.org/fhir/communicationrequest.html">CommunicationRequest</a> | <a href="http:/hl7.org/fhir/devicerequest.html">DeviceRequest</a> | <a href="http:/hl7.org/fhir/nutritionorder.html">NutritionOrder</a> | <a href="http:/hl7.org/fhir/task.html">Task</a> | <a href="http:/hl7.org/fhir/procedurerequest.html">ProcedureRequest</a> | <a href="http:/hl7.org/fhir/visionprescription.html">VisionPrescription</a> | <a href="http:/hl7.org/fhir/requestgroup.html">RequestGroup</a>)</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. </td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice problems_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Problems Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Problem list<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"11450-4"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">text</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck152.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_slice.png" alt="." style="background-color: white; background-color: inherit" title="Slice Definition" class="hierarchy"/> <span style="font-style: italic" title="null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="font-style: italic" href="http:/hl7.org/fhir/references.html">Reference</a><span style="font-style: italic">(</span><a style="opacity: 0.4; font-style: italic" href="http:/hl7.org/fhir/resource.html">Resource</a><span style="font-style: italic">)</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="font-style: italic">entry</span><br style="font-style: italic"/><span style="font-weight:bold; font-style: italic">Slice: </span><span style="font-style: italic">Unordered, Open by profile:reference</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck144.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_reference.png" alt="." style="background-color: white; background-color: inherit" title="Reference to another Resource" class="hierarchy"/> <span title="Slice sliceEntry: null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span><span style="opacity: 0.5">..</span><span style="opacity: 0.4">*</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/references.html">Reference</a>(<a href="http://hl7.org/fhir/us/core//StructureDefinition-us-core-condition.html">US Core Condition (a.k.a Problem) Profile</a>)</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice results_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Results Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Relevant diagnostic tests and/or laboratory data<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"30954-2"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">text</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck152.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_slice.png" alt="." style="background-color: white; background-color: inherit" title="Slice Definition" class="hierarchy"/> <span style="font-style: italic" title="null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="font-style: italic" href="http:/hl7.org/fhir/references.html">Reference</a><span style="font-style: italic">(</span><a style="opacity: 0.4; font-style: italic" href="http:/hl7.org/fhir/resource.html">Resource</a><span style="font-style: italic">)</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="font-style: italic">entry</span><br style="font-style: italic"/><span style="font-weight:bold; font-style: italic">Slice: </span><span style="font-style: italic">Unordered, Open by profile:reference</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck144.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_reference.png" alt="." style="background-color: white; background-color: inherit" title="Reference to another Resource" class="hierarchy"/> <span title="Slice sliceEntry: null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span><span style="opacity: 0.5">..</span><span style="opacity: 0.4">*</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/references.html">Reference</a>(<a href="http://hl7.org/fhir/us/core//StructureDefinition-us-core-observationresults.html">US Core Results Profile</a>)</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice review_of_systems_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Review of Systems Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Review of systems<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"10187-3"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck140.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">This section contains only human readable content</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck15.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice subjective_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Subjective Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck150.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Subjective<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"61150-9"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck140.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">This section contains only human readable content</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck05.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="Slice vital_signs_section: null">section</span><a name="Composition.section"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span>..<span style="opacity: 0.4">1</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#BackboneElement">BackboneElement</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Vital Signs Section</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck050.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">title</span><a name="Composition.section.title"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#string">string</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">title</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck050.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">code</span><a name="Composition.section.code"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Vital signs<br/><span style="font-weight:bold">Required Pattern: </span><span style="color: darkgreen">{"coding":[{"system":"http://loinc.org","code":"8716-3"}]}</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck050.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="." style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <span title="null">text</span><a name="Composition.section.text"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">1..1</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="opacity: 0.4" href="http:/hl7.org/fhir/datatypes.html#Narrative">Narrative</a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">text</td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck052.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_slice.png" alt="." style="background-color: white; background-color: inherit" title="Slice Definition" class="hierarchy"/> <span style="font-style: italic" title="null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a style="font-style: italic" href="http:/hl7.org/fhir/references.html">Reference</a><span style="font-style: italic">(</span><a style="opacity: 0.4; font-style: italic" href="http:/hl7.org/fhir/resource.html">Resource</a><span style="font-style: italic">)</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="font-style: italic">entry</span><br style="font-style: italic"/><span style="font-weight:bold; font-style: italic">Slice: </span><span style="font-style: italic">Unordered, Open by profile:reference</span></td></tr> <tr style="border: 0px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white;"><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck044.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end_slice.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_reference.png" alt="." style="background-color: white; background-color: inherit" title="Reference to another Resource" class="hierarchy"/> <span title="Slice sliceEntry: null">entry</span><a name="Composition.section.entry"> </a></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><span style="opacity: 0.4">0</span><span style="opacity: 0.5">..</span><span style="opacity: 0.4">*</span></td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="http:/hl7.org/fhir/references.html">Reference</a>(<a href="http:/hl7.org/fhir/vitalsigns.html">VitalSigns</a>)</td><td style="vertical-align: top; text-align : left; background-color: white; border: 0px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. </td></tr> <tr><td colspan="5" class="hierarchy"><br/><a href="http:/hl7.org/fhir/formats.html#table" title="Legend for this format"><img src="http:/hl7.org/fhir/help16.png" alt="doco" style="background-color: inherit"/> Documentation for this format</a></td></tr></table></div>" }, "url" : "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Progress-Note", "version" : "1.0.0", "name" : "C-CDA on FHIR Progress Note", "status" : "draft", "date" : "2018-04-07T06:53:01+10:00", "publisher" : "Lantana Consulting Group", "contact" : [ { "name" : "Sarah Gaunt", "telecom" : [ { "system" : "phone", "value" : "+6 141-029-2506", "use" : "work" }, { "system" : "email", "value" : "sarah.gaunt@lantanagroup.com", "use" : "work" } ] } ], "description" : "This profile represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. Taber's medical dictionary defines a Progress Note as An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note. Mosby's medical dictionary defines a Progress Note as Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned. A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833(e) defines the requirements of a Medicare Progress Report. ", "fhirVersion" : "3.0.1", "mapping" : [ { "identity" : "rim", "uri" : "http://hl7.org/v3", "name" : "RIM Mapping" }, { "identity" : "cda", "uri" : "http://hl7.org/v3/cda", "name" : "CDA (R2)" }, { "identity" : "w5", "uri" : "http://hl7.org/fhir/w5", "name" : "W5 Mapping" } ], "kind" : "resource", "abstract" : false, "contextType" : "resource", "context" : [ "Composition" ], "type" : "Composition", "baseDefinition" : "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-US-Realm-Header", "derivation" : "constraint", "snapshot" : { "element" : [ { "id" : "Composition", "path" : "Composition", "short" : "A set of resources composed into a single coherent clinical statement with clinical attestation", "definition" : "A set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.", "comment" : "While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.", "min" : 0, "max" : "*", "base" : { "path" : "Composition", "min" : 0, "max" : "*" }, "constraint" : [ { "key" : "dom-2", "severity" : "error", "human" : "If the resource is contained in another resource, it SHALL NOT contain nested Resources", "expression" : "contained.contained.empty()", "xpath" : "not(parent::f:contained and f:contained)", "source" : "DomainResource" }, { "key" : "dom-1", "severity" : "error", "human" : "If the resource is contained in another resource, it SHALL NOT contain any narrative", "expression" : "contained.text.empty()", "xpath" : "not(parent::f:contained and f:text)", "source" : "DomainResource" }, { "key" : "dom-4", "severity" : "error", "human" : "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated", "expression" : "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()", "xpath" : "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))", "source" : "DomainResource" }, { "key" : "dom-3", "severity" : "error", "human" : "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource", "expression" : "contained.where(('#'+id in %resource.descendants().reference).not()).empty()", "xpath" : "not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))", "source" : "DomainResource" } ], "mapping" : [ { "identity" : "rim", "map" : "Entity. Role, or Act" }, { "identity" : "rim", "map" : "Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]" }, { "identity" : "cda", "map" : "ClinicalDocument" }, { "identity" : "w5", "map" : "infrastructure.documents" } ] }, { "id" : "Composition.id", "path" : "Composition.id", "short" : "Logical id of this artifact", "definition" : "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.", "comment" : "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.", "min" : 0, "max" : "1", "base" : { "path" : "Resource.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "id" } ], "isSummary" : true }, { "id" : "Composition.meta", "path" : "Composition.meta", "short" : "Metadata about the resource", "definition" : "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.", "min" : 0, "max" : "1", "base" : { "path" : "Resource.meta", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Meta" } ], "isSummary" : true }, { "id" : "Composition.implicitRules", "path" : "Composition.implicitRules", "short" : "A set of rules under which this content was created", "definition" : "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.", "comment" : "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.", "min" : 0, "max" : "1", "base" : { "path" : "Resource.implicitRules", "min" : 0, "max" : "1" }, "type" : [ { "code" : "uri" } ], "isModifier" : true, "isSummary" : true }, { "id" : "Composition.language", "path" : "Composition.language", "short" : "language", "definition" : "The base language in which the resource is written.", "comment" : "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).", "min" : 1, "max" : "1", "base" : { "path" : "Resource.language", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet", "valueReference" : { "reference" : "http://hl7.org/fhir/ValueSet/all-languages" } }, { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "Language" }, { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding", "valueBoolean" : true } ], "strength" : "extensible", "description" : "A human language.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/languages" } } }, { "id" : "Composition.text", "path" : "Composition.text", "short" : "Text summary of the resource, for human interpretation", "definition" : "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.", "comment" : "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.", "alias" : [ "narrative", "html", "xhtml", "display" ], "min" : 0, "max" : "1", "base" : { "path" : "DomainResource.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "dom-1" ], "mapping" : [ { "identity" : "rim", "map" : "Act.text?" } ] }, { "id" : "Composition.contained", "path" : "Composition.contained", "short" : "Contained, inline Resources", "definition" : "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.", "comment" : "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.", "alias" : [ "inline resources", "anonymous resources", "contained resources" ], "min" : 0, "max" : "*", "base" : { "path" : "DomainResource.contained", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Resource" } ], "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.extension", "path" : "Composition.extension", "slicing" : { "discriminator" : [ { "type" : "value", "path" : "url" } ], "rules" : "open" }, "short" : "Extension", "definition" : "An Extension", "min" : 0, "max" : "*", "base" : { "path" : "DomainResource.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ] }, { "id" : "Composition.extension:data_enterer_extension", "path" : "Composition.extension", "sliceName" : "data_enterer_extension", "short" : "Extension", "definition" : "An Extension", "min" : 0, "max" : "1", "base" : { "path" : "DomainResource.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension", "profile" : "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer" } ], "condition" : [ "ele-1" ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "ext-1", "severity" : "error", "human" : "Must have either extensions or value[x], not both", "expression" : "extension.exists() != value.exists()", "xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source" : "Extension" } ] }, { "id" : "Composition.extension:data_enterer_extension.id", "path" : "Composition.extension.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). 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Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. 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The definition SHALL be a URI for the Structure Definition defining the extension.", "min" : 1, "max" : "1", "base" : { "path" : "Extension.url", "min" : 1, "max" : "1" }, "type" : [ { "code" : "uri" } ], "fixedUri" : "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer", "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.extension:data_enterer_extension.valueReference:valuereference", "path" : "Composition.extension.valueReference", "sliceName" : "valueReference", "short" : "Value of extension", "definition" : "Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).", "min" : 0, "max" : "1", "base" : { "path" : "Extension.value[x]", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner" } ], "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.extension:informant_extension", "path" : "Composition.extension", "sliceName" : "informant_extension", "label" : "informant", "short" : "informant", "definition" : "An Extension", "min" : 0, "max" : "*", "base" : { "path" : "DomainResource.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension", "profile" : "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Informant" } ], "condition" : [ "ele-1" ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "ext-1", "severity" : "error", "human" : "Must have either extensions or value[x], not both", "expression" : "extension.exists() != value.exists()", "xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source" : "Extension" } ] }, { "id" : "Composition.extension:informant_extension.id", "path" : "Composition.extension.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). 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Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. 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The definition SHALL be a URI for the Structure Definition defining the extension.", "min" : 1, "max" : "1", "base" : { "path" : "Extension.url", "min" : 1, "max" : "1" }, "type" : [ { "code" : "uri" } ], "fixedUri" : "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Informant", "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.extension:informant_extension.valueReference:valuereference", "path" : "Composition.extension.valueReference", "sliceName" : "valueReference", "short" : "Value of extension", "definition" : "Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).", "min" : 0, "max" : "1", "base" : { "path" : "Extension.value[x]", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/RelatedPerson" } ], "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.extension:information_recipient_extension", "path" : "Composition.extension", "sliceName" : "information_recipient_extension", "label" : "informationRecipient", "short" : "informationRecipient", "definition" : "An Extension", "min" : 0, "max" : "*", "base" : { "path" : "DomainResource.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension", "profile" : "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient" } ], "condition" : [ "ele-1" ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "ext-1", "severity" : "error", "human" : "Must have either extensions or value[x], not both", "expression" : "extension.exists() != value.exists()", "xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source" : "Extension" } ] }, { "id" : "Composition.extension:information_recipient_extension.id", "path" : "Composition.extension.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). 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The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.extension:performer_extension.url", "path" : "Composition.extension.url", "representation" : [ "xmlAttr" ], "short" : "identifies the meaning of the extension", "definition" : "Source of the definition for the extension code - a logical name or a URL.", "comment" : "The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.", "min" : 1, "max" : "1", "base" : { "path" : "Extension.url", "min" : 1, "max" : "1" }, "type" : [ { "code" : "uri" } ], "fixedUri" : "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Performer", "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.extension:performer_extension.valueReference:valuereference", "path" : "Composition.extension.valueReference", "sliceName" : "valueReference", "short" : "Value of extension", "definition" : "Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).", "min" : 0, "max" : "1", "base" : { "path" : "Extension.value[x]", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner" } ], "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.extension:authorization_extension", "path" : "Composition.extension", "sliceName" : "authorization_extension", "label" : "authorization", "short" : "authorization", "definition" : "An Extension", "min" : 0, "max" : "*", "base" : { "path" : "DomainResource.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension", "profile" : "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Authorization" } ], "condition" : [ "ele-1" ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "ext-1", "severity" : "error", "human" : "Must have either extensions or value[x], not both", "expression" : "extension.exists() != value.exists()", "xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source" : "Extension" } ] }, { "id" : "Composition.extension:authorization_extension.id", "path" : "Composition.extension.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.extension:authorization_extension.extension", "path" : "Composition.extension.extension", "slicing" : { "discriminator" : [ { "type" : "value", "path" : "url" } ], "description" : "Extensions are always sliced by (at least) url", "rules" : "open" }, "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.extension:authorization_extension.url", "path" : "Composition.extension.url", "representation" : [ "xmlAttr" ], "short" : "identifies the meaning of the extension", "definition" : "Source of the definition for the extension code - a logical name or a URL.", "comment" : "The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.", "min" : 1, "max" : "1", "base" : { "path" : "Extension.url", "min" : 1, "max" : "1" }, "type" : [ { "code" : "uri" } ], "fixedUri" : "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Authorization", "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.extension:authorization_extension.valueReference:valuereference", "path" : "Composition.extension.valueReference", "sliceName" : "valueReference", "short" : "Value of extension", "definition" : "Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).", "min" : 0, "max" : "1", "base" : { "path" : "Extension.value[x]", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Consent" } ], "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.extension:order_extension", "path" : "Composition.extension", "sliceName" : "order_extension", "label" : "authorization", "short" : "authorization", "definition" : "An Extension", "min" : 0, "max" : "*", "base" : { "path" : "DomainResource.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension", "profile" : "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-In-Fulfillment-Of-Order" } ], "condition" : [ "ele-1" ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "ext-1", "severity" : "error", "human" : "Must have either extensions or value[x], not both", "expression" : "extension.exists() != value.exists()", "xpath" : "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source" : "Extension" } ] }, { "id" : "Composition.extension:order_extension.id", "path" : "Composition.extension.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.extension:order_extension.extension", "path" : "Composition.extension.extension", "slicing" : { "discriminator" : [ { "type" : "value", "path" : "url" } ], "description" : "Extensions are always sliced by (at least) url", "rules" : "open" }, "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.extension:order_extension.url", "path" : "Composition.extension.url", "representation" : [ "xmlAttr" ], "short" : "identifies the meaning of the extension", "definition" : "Source of the definition for the extension code - a logical name or a URL.", "comment" : "The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.", "min" : 1, "max" : "1", "base" : { "path" : "Extension.url", "min" : 1, "max" : "1" }, "type" : [ { "code" : "uri" } ], "fixedUri" : "http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-In-Fulfillment-Of-Order", "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.extension:order_extension.valueReference:valuereference", "path" : "Composition.extension.valueReference", "sliceName" : "valueReference", "short" : "Value of extension", "definition" : "Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).", "min" : 0, "max" : "1", "base" : { "path" : "Extension.value[x]", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/ProcedureRequest" } ], "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.modifierExtension", "path" : "Composition.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "DomainResource.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.identifier", "path" : "Composition.identifier", "short" : "identifier", "definition" : "Logical identifier for the composition, assigned when created. This identifier stays constant as the composition is changed over time.", "comment" : "See discussion in resource definition for how these relate.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.identifier", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Identifier" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "Document.id / Document.setId" }, { "identity" : "cda", "map" : ".setId" }, { "identity" : "w5", "map" : "id" } ] }, { "id" : "Composition.status", "path" : "Composition.status", "short" : "preliminary | final | amended | entered-in-error", "definition" : "The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.", "comment" : "If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.", "requirements" : "Need to be able to mark interim, amended, or withdrawn compositions or documents.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.status", "min" : 1, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionStatus" } ], "strength" : "required", "description" : "The workflow/clinical status of the composition.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/composition-status" } }, "mapping" : [ { "identity" : "rim", "map" : "interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "status" } ] }, { "id" : "Composition.type", "path" : "Composition.type", "short" : "type", "definition" : "Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition.", "comment" : "For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.", "requirements" : "Key metadata element describing the composition, used in searching/filtering.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.type", "min" : 1, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "isSummary" : true, "binding" : { "strength" : "required", "valueSetReference" : { "reference" : "http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.8.1" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.class", "path" : "Composition.class", "short" : "Categorization of Composition", "definition" : "A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.", "comment" : "This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)).", "requirements" : "Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.class", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "DocumentClass" } ], "strength" : "example", "description" : "High-level kind of a clinical document at a macro level.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-classcodes" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.subject", "path" : "Composition.subject", "short" : "Who and/or what the composition is about", "definition" : "Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).", "comment" : "For clinical documents, this is usually the patient.", "requirements" : "Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.subject", "min" : 1, "max" : "1" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Group" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : ".participation[typeCode="SBJ"].role[typeCode="PAT"]" }, { "identity" : "cda", "map" : ".recordTarget" }, { "identity" : "w5", "map" : "who.focus" } ] }, { "id" : "Composition.encounter", "path" : "Composition.encounter", "short" : "Context of the Composition", "definition" : "Describes the clinical encounter or type of care this documentation is associated with.", "requirements" : "Provides context for the composition and supports searching.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.encounter", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Encounter" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])" }, { "identity" : "cda", "map" : ".componentOf.encompassingEncounter" }, { "identity" : "w5", "map" : "context" } ] }, { "id" : "Composition.date", "path" : "Composition.date", "short" : "date", "definition" : "The composition editing time, when the composition was last logically changed by the author.", "comment" : "The Last Modified Date on the composition may be after the date of the document was attested without being changed.", "requirements" : "dateTime is used for tracking, organizing versions and searching.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.date", "min" : 1, "max" : "1" }, "type" : [ { "code" : "dateTime" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : ".effectiveTime[type="TS"]" }, { "identity" : "cda", "map" : ".effectiveTime" }, { "identity" : "w5", "map" : "when.done" } ] }, { "id" : "Composition.author", "path" : "Composition.author", "short" : "Who and/or what authored the composition", "definition" : "Identifies who is responsible for the information in the composition, not necessarily who typed it in.", "requirements" : "Identifies who is responsible for the content.", "min" : 1, "max" : "*", "base" : { "path" : "Composition.author", "min" : 1, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/PractitionerRole" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Device" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/RelatedPerson" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : ".participation[typeCode="AUT"].role[classCode="ASSIGNED"]" }, { "identity" : "cda", "map" : ".author.assignedAuthor" }, { "identity" : "w5", "map" : "who.author" } ] }, { "id" : "Composition.title", "path" : "Composition.title", "label" : "Document Title", "short" : "Document Title", "definition" : "Official human-readable label for the composition.", "comment" : "For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.title", "min" : 1, "max" : "1" }, "type" : [ { "code" : "string" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.confidentiality", "path" : "Composition.confidentiality", "short" : "confidentiality", "definition" : "The code specifying the level of confidentiality of the Composition.", "comment" : "The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.confidentiality", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "DocumentConfidentiality" } ], "strength" : "required", "description" : "Codes specifying the level of confidentiality of the composition.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/v3-ConfidentialityClassification" } }, "mapping" : [ { "identity" : "rim", "map" : ".confidentialityCode" }, { "identity" : "cda", "map" : ".confidentialityCode" } ] }, { "id" : "Composition.attester", "path" : "Composition.attester", "slicing" : { "discriminator" : [ { "type" : "value", "path" : "mode" } ], "rules" : "open" }, "short" : "Attests to accuracy of composition", "definition" : "A participant who has attested to the accuracy of the composition/document.", "comment" : "Only list each attester once.", "requirements" : "Identifies responsibility for the accuracy of the composition content.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.attester", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : ".participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]" }, { "identity" : "cda", "map" : ".authenticator/.legalAuthenticator" } ] }, { "id" : "Composition.attester.id", "path" : "Composition.attester.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.attester.extension", "path" : "Composition.attester.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.attester.modifierExtension", "path" : "Composition.attester.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.attester.mode", "path" : "Composition.attester.mode", "short" : "personal | professional | legal | official", "definition" : "The type of attestation the authenticator offers.", "comment" : "Use more than one code where a single attester has more than one mode (professional and legal are often paired).", "requirements" : "Indicates the level of authority of the attestation.", "min" : 1, "max" : "*", "base" : { "path" : "Composition.attester.mode", "min" : 1, "max" : "*" }, "type" : [ { "code" : "code" } ], "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionAttestationMode" } ], "strength" : "required", "description" : "The way in which a person authenticated a composition.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/composition-attestation-mode" } }, "mapping" : [ { "identity" : "rim", "map" : "unique(./modeCode)" }, { "identity" : "cda", "map" : "implied by .authenticator/.legalAuthenticator" } ] }, { "id" : "Composition.attester.time", "path" : "Composition.attester.time", "short" : "When the composition was attested", "definition" : "When the composition was attested by the party.", "requirements" : "Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).", "min" : 0, "max" : "1", "base" : { "path" : "Composition.attester.time", "min" : 0, "max" : "1" }, "type" : [ { "code" : "dateTime" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "./time[type="TS" and isNormalDatatype()]" }, { "identity" : "cda", "map" : ".authenticator.time" } ] }, { "id" : "Composition.attester.party", "path" : "Composition.attester.party", "short" : "Who attested the composition", "definition" : "Who attested the composition in the specified way.", "requirements" : "Identifies who has taken on the responsibility for accuracy of the composition content.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.attester.party", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Patient" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Practitioner" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Organization" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]" }, { "identity" : "cda", "map" : ".authenticator.assignedEnttty" }, { "identity" : "w5", "map" : "who.witness" } ] }, { "id" : "Composition.attester:legal_attester", "path" : "Composition.attester", "sliceName" : "legal_attester", "short" : "attester", "definition" : "A participant who has attested to the accuracy of the composition/document.", "comment" : "Only list each attester once.", "requirements" : "Identifies responsibility for the accuracy of the composition content.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.attester", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : ".participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]" }, { "identity" : "cda", "map" : ".authenticator/.legalAuthenticator" } ] }, { "id" : "Composition.attester:legal_attester.id", "path" : "Composition.attester.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.attester:legal_attester.extension", "path" : "Composition.attester.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.attester:legal_attester.modifierExtension", "path" : "Composition.attester.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.attester:legal_attester.mode", "path" : "Composition.attester.mode", "short" : "mode", "definition" : "The type of attestation the authenticator offers.", "comment" : "Use more than one code where a single attester has more than one mode (professional and legal are often paired).", "requirements" : "Indicates the level of authority of the attestation.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.attester.mode", "min" : 1, "max" : "*" }, "type" : [ { "code" : "code" } ], "fixedCode" : "legal", "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionAttestationMode" } ], "strength" : "required", "description" : "The way in which a person authenticated a composition.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/composition-attestation-mode" } }, "mapping" : [ { "identity" : "rim", "map" : "unique(./modeCode)" }, { "identity" : "cda", "map" : "implied by .authenticator/.legalAuthenticator" } ] }, { "id" : "Composition.attester:legal_attester.time", "path" : "Composition.attester.time", "short" : "When the composition was attested", "definition" : "When the composition was attested by the party.", "requirements" : "Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).", "min" : 0, "max" : "1", "base" : { "path" : "Composition.attester.time", "min" : 0, "max" : "1" }, "type" : [ { "code" : "dateTime" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "./time[type="TS" and isNormalDatatype()]" }, { "identity" : "cda", "map" : ".authenticator.time" } ] }, { "id" : "Composition.attester:legal_attester.party", "path" : "Composition.attester.party", "short" : "party", "definition" : "Who attested the composition in the specified way.", "requirements" : "Identifies who has taken on the responsibility for accuracy of the composition content.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.attester.party", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]" }, { "identity" : "cda", "map" : ".authenticator.assignedEnttty" }, { "identity" : "w5", "map" : "who.witness" } ] }, { "id" : "Composition.attester:professional_attester", "path" : "Composition.attester", "sliceName" : "professional_attester", "short" : "attester", "definition" : "A participant who has attested to the accuracy of the composition/document.", "comment" : "Only list each attester once.", "requirements" : "Identifies responsibility for the accuracy of the composition content.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.attester", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : ".participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]" }, { "identity" : "cda", "map" : ".authenticator/.legalAuthenticator" } ] }, { "id" : "Composition.attester:professional_attester.id", "path" : "Composition.attester.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). 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Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.attester:professional_attester.modifierExtension", "path" : "Composition.attester.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.attester:professional_attester.mode", "path" : "Composition.attester.mode", "short" : "mode", "definition" : "The type of attestation the authenticator offers.", "comment" : "Use more than one code where a single attester has more than one mode (professional and legal are often paired).", "requirements" : "Indicates the level of authority of the attestation.", "min" : 1, "max" : "*", "base" : { "path" : "Composition.attester.mode", "min" : 1, "max" : "*" }, "type" : [ { "code" : "code" } ], "fixedCode" : "professional", "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionAttestationMode" } ], "strength" : "required", "description" : "The way in which a person authenticated a composition.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/composition-attestation-mode" } }, "mapping" : [ { "identity" : "rim", "map" : "unique(./modeCode)" }, { "identity" : "cda", "map" : "implied by .authenticator/.legalAuthenticator" } ] }, { "id" : "Composition.attester:professional_attester.time", "path" : "Composition.attester.time", "short" : "When the composition was attested", "definition" : "When the composition was attested by the party.", "requirements" : "Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).", "min" : 0, "max" : "1", "base" : { "path" : "Composition.attester.time", "min" : 0, "max" : "1" }, "type" : [ { "code" : "dateTime" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "./time[type="TS" and isNormalDatatype()]" }, { "identity" : "cda", "map" : ".authenticator.time" } ] }, { "id" : "Composition.attester:professional_attester.party", "path" : "Composition.attester.party", "short" : "party", "definition" : "Who attested the composition in the specified way.", "requirements" : "Identifies who has taken on the responsibility for accuracy of the composition content.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.attester.party", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]" }, { "identity" : "cda", "map" : ".authenticator.assignedEnttty" }, { "identity" : "w5", "map" : "who.witness" } ] }, { "id" : "Composition.attester:personal_attester", "path" : "Composition.attester", "sliceName" : "personal_attester", "short" : "attester", "definition" : "A participant who has attested to the accuracy of the composition/document.", "comment" : "Only list each attester once.", "requirements" : "Identifies responsibility for the accuracy of the composition content.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.attester", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : ".participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]" }, { "identity" : "cda", "map" : ".authenticator/.legalAuthenticator" } ] }, { "id" : "Composition.attester:personal_attester.id", "path" : "Composition.attester.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). 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Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.attester:personal_attester.modifierExtension", "path" : "Composition.attester.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.attester:personal_attester.mode", "path" : "Composition.attester.mode", "short" : "mode", "definition" : "The type of attestation the authenticator offers.", "comment" : "Use more than one code where a single attester has more than one mode (professional and legal are often paired).", "requirements" : "Indicates the level of authority of the attestation.", "min" : 1, "max" : "*", "base" : { "path" : "Composition.attester.mode", "min" : 1, "max" : "*" }, "type" : [ { "code" : "code" } ], "fixedCode" : "personal", "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionAttestationMode" } ], "strength" : "required", "description" : "The way in which a person authenticated a composition.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/composition-attestation-mode" } }, "mapping" : [ { "identity" : "rim", "map" : "unique(./modeCode)" }, { "identity" : "cda", "map" : "implied by .authenticator/.legalAuthenticator" } ] }, { "id" : "Composition.attester:personal_attester.time", "path" : "Composition.attester.time", "short" : "When the composition was attested", "definition" : "When the composition was attested by the party.", "requirements" : "Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).", "min" : 0, "max" : "1", "base" : { "path" : "Composition.attester.time", "min" : 0, "max" : "1" }, "type" : [ { "code" : "dateTime" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "./time[type="TS" and isNormalDatatype()]" }, { "identity" : "cda", "map" : ".authenticator.time" } ] }, { "id" : "Composition.attester:personal_attester.party", "path" : "Composition.attester.party", "short" : "party", "definition" : "Who attested the composition in the specified way.", "requirements" : "Identifies who has taken on the responsibility for accuracy of the composition content.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.attester.party", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]" }, { "identity" : "cda", "map" : ".authenticator.assignedEnttty" }, { "identity" : "w5", "map" : "who.witness" } ] }, { "id" : "Composition.custodian", "path" : "Composition.custodian", "label" : "custodian", "short" : "custodian", "definition" : "Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.", "comment" : "This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.", "requirements" : "Identifies where to go to find the current version, where to report issues, etc.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.custodian", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : ".participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]" }, { "identity" : "cda", "map" : ".custodian.assignedCustodian" } ] }, { "id" : "Composition.relatesTo", "path" : "Composition.relatesTo", "short" : "Relationships to other compositions/documents", "definition" : "Relationships that this composition has with other compositions or documents that already exist.", "comment" : "A document is a version specific composition.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.relatesTo", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship" }, { "identity" : "cda", "map" : ".relatedDocument" } ] }, { "id" : "Composition.relatesTo.id", "path" : "Composition.relatesTo.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.relatesTo.extension", "path" : "Composition.relatesTo.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.relatesTo.modifierExtension", "path" : "Composition.relatesTo.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.relatesTo.code", "path" : "Composition.relatesTo.code", "short" : "replaces | transforms | signs | appends", "definition" : "The type of relationship that this composition has with anther composition or document.", "comment" : "If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.relatesTo.code", "min" : 1, "max" : "1" }, "type" : [ { "code" : "code" } ], "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "DocumentRelationshipType" } ], "strength" : "required", "description" : "The type of relationship between documents.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/document-relationship-type" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship.typeCode" }, { "identity" : "cda", "map" : ".relatedDocument.typeCode" } ] }, { "id" : "Composition.relatesTo.target[x]", "path" : "Composition.relatesTo.target[x]", "short" : "Target of the relationship", "definition" : "The target composition/document of this relationship.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.relatesTo.target[x]", "min" : 1, "max" : "1" }, "type" : [ { "code" : "Identifier" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Composition" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : ".target[classCode="DOC", moodCode="EVN"].id" }, { "identity" : "cda", "map" : ".relatedDocument.id" } ] }, { "id" : "Composition.event", "path" : "Composition.event", "short" : "The clinical service(s) being documented", "definition" : "The clinical service, such as a colonoscopy or an appendectomy, being documented.", "comment" : "The event needs to be consistent with the type element, though can provide further information if desired.", "requirements" : "Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.event", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']" }, { "identity" : "cda", "map" : ".documentationOf.serviceEvent" } ] }, { "id" : "Composition.event.id", "path" : "Composition.event.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.event.extension", "path" : "Composition.event.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.event.modifierExtension", "path" : "Composition.event.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.event.code", "path" : "Composition.event.code", "short" : "Code(s) that apply to the event being documented", "definition" : "This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.", "comment" : "An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.event.code", "min" : 0, "max" : "*" }, "type" : [ { "code" : "CodeableConcept" } ], "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "DocumentEventType" } ], "strength" : "example", "description" : "This list of codes represents the main clinical acts being documented.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/v3-ActCode" } }, "mapping" : [ { "identity" : "rim", "map" : ".code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.event.period", "path" : "Composition.event.period", "short" : "The period covered by the documentation", "definition" : "The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.event.period", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Period" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : ".effectiveTime" }, { "identity" : "cda", "map" : ".effectiveTime" } ] }, { "id" : "Composition.event.detail", "path" : "Composition.event.detail", "short" : "The event(s) being documented", "definition" : "The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.event.detail", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode="SUBJ"].target" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "slicing" : { "discriminator" : [ { "type" : "value", "path" : "code" } ], "rules" : "open" }, "short" : "Composition is broken into sections", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section.title", "path" : "Composition.section.title", "short" : "Label for section (e.g. for ToC)", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section.code", "path" : "Composition.section.code", "short" : "Classification of section (recommended)", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section.text", "path" : "Composition.section.text", "short" : "Text summary of the section, for human interpretation", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section.entry", "path" : "Composition.section.entry", "short" : "A reference to data that supports this section", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:assessment_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "assessment_section", "label" : "Assessment Section", "short" : "Assessment Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:assessment_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:assessment_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:assessment_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:assessment_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:assessment_section.code", "path" : "Composition.section.code", "label" : "Assessments", "short" : "Assessments", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "51848-0" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:assessment_section.text", "path" : "Composition.section.text", "short" : "This section contains only human readable content", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:assessment_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:assessment_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:assessment_section.entry", "path" : "Composition.section.entry", "short" : "A reference to data that supports this section", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:assessment_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:assessment_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:assessment_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:allergies_and_intolerances_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "allergies_and_intolerances_section", "label" : "Allergies and Intolerances Section", "short" : "Allergies and Intolerances Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:allergies_and_intolerances_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:allergies_and_intolerances_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:allergies_and_intolerances_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:allergies_and_intolerances_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:allergies_and_intolerances_section.code", "path" : "Composition.section.code", "label" : "Allergies, adverse reactions, alerts", "short" : "Allergies, adverse reactions, alerts", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "48765-2" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:allergies_and_intolerances_section.text", "path" : "Composition.section.text", "short" : "text", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:allergies_and_intolerances_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:allergies_and_intolerances_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:allergies_and_intolerances_section.entry", "path" : "Composition.section.entry", "slicing" : { "discriminator" : [ { "type" : "profile", "path" : "reference" } ], "rules" : "open" }, "short" : "entry", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:allergies_and_intolerances_section.entry:sliceentry", "path" : "Composition.section.entry", "sliceName" : "sliceEntry", "short" : "A reference to data that supports this section", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:allergies_and_intolerances_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:allergies_and_intolerances_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:allergies_and_intolerances_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:assessment_and_plan_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "assessment_and_plan_section", "label" : "Assessment and Plan Section", "short" : "Assessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:assessment_and_plan_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:assessment_and_plan_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:assessment_and_plan_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:assessment_and_plan_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:assessment_and_plan_section.code", "path" : "Composition.section.code", "label" : "Assessment and plan", "short" : "Assessment and plan", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "51847-2" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:assessment_and_plan_section.text", "path" : "Composition.section.text", "short" : "text", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:assessment_and_plan_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:assessment_and_plan_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:assessment_and_plan_section.entry", "path" : "Composition.section.entry", "slicing" : { "discriminator" : [ { "type" : "profile", "path" : "reference" } ], "rules" : "open" }, "short" : "A reference to data that supports this section", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:assessment_and_plan_section.entry:sliceentry", "path" : "Composition.section.entry", "sliceName" : "sliceEntry", "short" : "This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Observation" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Communication" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:assessment_and_plan_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:assessment_and_plan_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:assessment_and_plan_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:chief_complaint_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "chief_complaint_section", "label" : "Chief Complaint Section", "short" : "Chief Complaint Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:chief_complaint_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:chief_complaint_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:chief_complaint_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:chief_complaint_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:chief_complaint_section.code", "path" : "Composition.section.code", "label" : "Chief complaint", "short" : "Chief complaint", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "10154-3" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:chief_complaint_section.text", "path" : "Composition.section.text", "short" : "This section contains only human readable content", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:chief_complaint_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:chief_complaint_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:chief_complaint_section.entry", "path" : "Composition.section.entry", "short" : "A reference to data that supports this section", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:chief_complaint_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:chief_complaint_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:chief_complaint_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:instructions_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "instructions_section", "label" : "Instructions Section", "short" : "Instructions Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:instructions_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:instructions_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:instructions_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:instructions_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:instructions_section.code", "path" : "Composition.section.code", "label" : "Instructions", "short" : "Instructions", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "69730-0" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:instructions_section.text", "path" : "Composition.section.text", "short" : "This section contains only human readable content", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:instructions_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:instructions_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:instructions_section.entry", "path" : "Composition.section.entry", "short" : "A reference to data that supports this section", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:instructions_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:instructions_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:instructions_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:interventions_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "interventions_section", "label" : "Interventions Section", "short" : "Interventions Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:interventions_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:interventions_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:interventions_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:interventions_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:interventions_section.code", "path" : "Composition.section.code", "label" : "Interventions provided", "short" : "Interventions provided", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "62387-6" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:interventions_section.text", "path" : "Composition.section.text", "short" : "text", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:interventions_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:interventions_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:interventions_section.entry", "path" : "Composition.section.entry", "slicing" : { "discriminator" : [ { "type" : "profile", "path" : "reference" } ], "rules" : "open" }, "short" : "entry", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:interventions_section.entry:interventions_section_slice", "path" : "Composition.section.entry", "sliceName" : "interventions_section_slice", "short" : "This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/List" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/RequestGroup" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:interventions_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:interventions_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:interventions_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:medications_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "medications_section", "label" : "Medications Section", "short" : "Medications Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:medications_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:medications_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:medications_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:medications_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:medications_section.code", "path" : "Composition.section.code", "label" : "History of medication use", "short" : "History of medication use", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "10160-0" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:medications_section.text", "path" : "Composition.section.text", "short" : "text", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:medications_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:medications_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:medications_section.entry", "path" : "Composition.section.entry", "slicing" : { "discriminator" : [ { "type" : "profile", "path" : "reference" } ], "rules" : "open" }, "short" : "entry", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:medications_section.entry:sliceentry", "path" : "Composition.section.entry", "sliceName" : "sliceEntry", "short" : "A reference to data that supports this section", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationstatement" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:medications_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:medications_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:medications_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:nutrition_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "nutrition_section", "label" : "Nutrition Section", "short" : "Nutrition Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:nutrition_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:nutrition_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:nutrition_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:nutrition_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:nutrition_section.code", "path" : "Composition.section.code", "label" : "Diet and nutrition", "short" : "Diet and nutrition", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "61144-2" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:nutrition_section.text", "path" : "Composition.section.text", "short" : "text", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:nutrition_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:nutrition_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:nutrition_section.entry", "path" : "Composition.section.entry", "slicing" : { "discriminator" : [ { "type" : "profile", "path" : "reference" } ], "rules" : "open" }, "short" : "entry", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:nutrition_section.entry:sliceentry", "path" : "Composition.section.entry", "sliceName" : "sliceEntry", "short" : "This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Observation" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:nutrition_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:nutrition_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:nutrition_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:objective_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "objective_section", "label" : "Objective Section", "short" : "Objective Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:objective_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:objective_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:objective_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:objective_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:objective_section.code", "path" : "Composition.section.code", "label" : "Objective", "short" : "Objective", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "61149-1" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:objective_section.text", "path" : "Composition.section.text", "short" : "This section contains only human readable content", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:objective_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:objective_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:objective_section.entry", "path" : "Composition.section.entry", "short" : "A reference to data that supports this section", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:objective_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:objective_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:objective_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:physical_exam_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "physical_exam_section", "label" : "Physical Exam Section", "short" : "Physical Exam Section", "definition" : "The root of the sections that make up the composition.", "comment" : "Physical Exam Section", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:physical_exam_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:physical_exam_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:physical_exam_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:physical_exam_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:physical_exam_section.code", "path" : "Composition.section.code", "label" : "Physical findings", "short" : "Physical findings", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "29545-1" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:physical_exam_section.text", "path" : "Composition.section.text", "short" : "text", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:physical_exam_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:physical_exam_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:physical_exam_section.entry", "path" : "Composition.section.entry", "slicing" : { "discriminator" : [ { "type" : "profile", "path" : "reference" } ], "rules" : "open" }, "short" : "entry", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:physical_exam_section.entry:sliceentry", "path" : "Composition.section.entry", "sliceName" : "sliceEntry", "short" : "This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Observation" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:physical_exam_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:physical_exam_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:physical_exam_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:plan_of_treatment_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "plan_of_treatment_section", "label" : "Plan of Treatment Section", "short" : "Plan of Treatment Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:plan_of_treatment_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:plan_of_treatment_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:plan_of_treatment_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:plan_of_treatment_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:plan_of_treatment_section.code", "path" : "Composition.section.code", "label" : "Plan of Treatment", "short" : "Plan of Treatment", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "18776-5" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:plan_of_treatment_section.text", "path" : "Composition.section.text", "short" : "text", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:plan_of_treatment_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:plan_of_treatment_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:plan_of_treatment_section.entry", "path" : "Composition.section.entry", "slicing" : { "discriminator" : [ { "type" : "profile", "path" : "reference" } ], "rules" : "open" }, "short" : "entry", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:plan_of_treatment_section.entry:sliceentry", "path" : "Composition.section.entry", "sliceName" : "sliceEntry", "short" : "This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Communication" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Appointment" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/CommunicationRequest" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/DeviceRequest" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/NutritionOrder" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Task" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/ProcedureRequest" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/VisionPrescription" }, { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/RequestGroup" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:plan_of_treatment_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:plan_of_treatment_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:plan_of_treatment_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:problems_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "problems_section", "label" : "Problems Section", "short" : "Problems Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:problems_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:problems_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:problems_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:problems_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:problems_section.code", "path" : "Composition.section.code", "label" : "Problem list", "short" : "Problem list", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "11450-4" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:problems_section.text", "path" : "Composition.section.text", "short" : "text", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:problems_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:problems_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:problems_section.entry", "path" : "Composition.section.entry", "slicing" : { "discriminator" : [ { "type" : "profile", "path" : "reference" } ], "rules" : "open" }, "short" : "entry", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:problems_section.entry:sliceentry", "path" : "Composition.section.entry", "sliceName" : "sliceEntry", "short" : "A reference to data that supports this section", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:problems_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:problems_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:problems_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:results_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "results_section", "label" : "Results Section", "short" : "Results Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:results_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:results_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:results_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:results_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:results_section.code", "path" : "Composition.section.code", "label" : "Relevant diagnostic tests and/or laboratory data", "short" : "Relevant diagnostic tests and/or laboratory data", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "30954-2" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:results_section.text", "path" : "Composition.section.text", "short" : "text", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:results_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:results_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:results_section.entry", "path" : "Composition.section.entry", "slicing" : { "discriminator" : [ { "type" : "profile", "path" : "reference" } ], "rules" : "open" }, "short" : "entry", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:results_section.entry:sliceentry", "path" : "Composition.section.entry", "sliceName" : "sliceEntry", "short" : "A reference to data that supports this section", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:results_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:results_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:results_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:review_of_systems_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "review_of_systems_section", "label" : "Review of Systems Section", "short" : "Review of Systems Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:review_of_systems_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:review_of_systems_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:review_of_systems_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:review_of_systems_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:review_of_systems_section.code", "path" : "Composition.section.code", "label" : "Review of systems", "short" : "Review of systems", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "10187-3" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:review_of_systems_section.text", "path" : "Composition.section.text", "short" : "This section contains only human readable content", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:review_of_systems_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:review_of_systems_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:review_of_systems_section.entry", "path" : "Composition.section.entry", "short" : "A reference to data that supports this section", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:review_of_systems_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:review_of_systems_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:review_of_systems_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:subjective_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "subjective_section", "label" : "Subjective Section", "short" : "Subjective Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:subjective_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:subjective_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:subjective_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:subjective_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:subjective_section.code", "path" : "Composition.section.code", "label" : "Subjective", "short" : "Subjective", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "61150-9" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:subjective_section.text", "path" : "Composition.section.text", "short" : "This section contains only human readable content", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:subjective_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:subjective_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:subjective_section.entry", "path" : "Composition.section.entry", "short" : "A reference to data that supports this section", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:subjective_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:subjective_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:subjective_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] }, { "id" : "Composition.section:vital_signs_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "vital_signs_section", "label" : "Vital Signs Section", "short" : "Vital Signs Section", "definition" : "The root of the sections that make up the composition.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section", "min" : 0, "max" : "*" }, "type" : [ { "code" : "BackboneElement" } ], "constraint" : [ { "key" : "ele-1", "severity" : "error", "human" : "All FHIR elements must have a @value or children", "expression" : "hasValue() | (children().count() > id.count())", "xpath" : "@value|f:*|h:div", "source" : "Element" }, { "key" : "cmp-1", "severity" : "error", "human" : "A section must at least one of text, entries, or sub-sections", "expression" : "text.exists() or entry.exists() or section.exists()", "xpath" : "exists(f:text) or exists(f:entry) or exists(f:section)", "source" : "Composition.section" }, { "key" : "cmp-2", "severity" : "error", "human" : "A section can only have an emptyReason if it is empty", "expression" : "emptyReason.empty() or entry.empty()", "xpath" : "not(exists(f:emptyReason) and exists(f:entry))", "source" : "Composition.section" } ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.structuredBody.component.section" } ] }, { "id" : "Composition.section:vital_signs_section.id", "path" : "Composition.section.id", "representation" : [ "xmlAttr" ], "short" : "xml:id (or equivalent in JSON)", "definition" : "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min" : 0, "max" : "1", "base" : { "path" : "Element.id", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:vital_signs_section.extension", "path" : "Composition.section.extension", "short" : "Additional Content defined by implementations", "definition" : "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content" ], "min" : 0, "max" : "*", "base" : { "path" : "Element.extension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "mapping" : [ { "identity" : "rim", "map" : "n/a" } ] }, { "id" : "Composition.section:vital_signs_section.modifierExtension", "path" : "Composition.section.modifierExtension", "short" : "Extensions that cannot be ignored", "definition" : "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comment" : "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias" : [ "extensions", "user content", "modifiers" ], "min" : 0, "max" : "*", "base" : { "path" : "BackboneElement.modifierExtension", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Extension" } ], "isModifier" : true, "isSummary" : true, "mapping" : [ { "identity" : "rim", "map" : "N/A" } ] }, { "id" : "Composition.section:vital_signs_section.title", "path" : "Composition.section.title", "short" : "title", "definition" : "The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.", "comment" : "The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.", "requirements" : "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.", "alias" : [ "header", "label", "caption" ], "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.title", "min" : 0, "max" : "1" }, "type" : [ { "code" : "string" } ], "mapping" : [ { "identity" : "rim", "map" : "./title" }, { "identity" : "cda", "map" : ".title" } ] }, { "id" : "Composition.section:vital_signs_section.code", "path" : "Composition.section.code", "label" : "Vital signs", "short" : "Vital signs", "definition" : "A code identifying the kind of content contained within the section. This must be consistent with the section title.", "comment" : "The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.", "requirements" : "Provides computable standardized labels to topics within the document.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.code", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "8716-3" } ] }, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "CompositionSectionType" } ], "strength" : "example", "description" : "Classification of a section of a composition/document.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/doc-section-codes" } }, "mapping" : [ { "identity" : "rim", "map" : "./code" }, { "identity" : "cda", "map" : ".code" } ] }, { "id" : "Composition.section:vital_signs_section.text", "path" : "Composition.section.text", "short" : "text", "definition" : "A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.", "comment" : "Document profiles may define what content should be represented in the narrative to ensure clinical safety.", "min" : 1, "max" : "1", "base" : { "path" : "Composition.section.text", "min" : 0, "max" : "1" }, "type" : [ { "code" : "Narrative" } ], "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : ".text" }, { "identity" : "cda", "map" : ".text" } ] }, { "id" : "Composition.section:vital_signs_section.mode", "path" : "Composition.section.mode", "short" : "working | snapshot | changes", "definition" : "How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.", "comment" : "This element is labeled as a modifier because a change list must not be mis-understood as a complete list.", "requirements" : "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.mode", "min" : 0, "max" : "1" }, "type" : [ { "code" : "code" } ], "isModifier" : true, "isSummary" : true, "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionMode" } ], "strength" : "required", "description" : "The processing mode that applies to this section.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-mode" } }, "mapping" : [ { "identity" : "rim", "map" : ".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value" }, { "identity" : "cda", "map" : "n/a" }, { "identity" : "w5", "map" : "class" } ] }, { "id" : "Composition.section:vital_signs_section.orderedBy", "path" : "Composition.section.orderedBy", "short" : "Order of section entries", "definition" : "Specifies the order applied to the items in the section entries.", "comment" : "Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.", "requirements" : "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.orderedBy", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEntryOrder" } ], "strength" : "preferred", "description" : "What order applies to the items in the entry.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-order" } }, "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP].sequenceNumber > 1" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:vital_signs_section.entry", "path" : "Composition.section.entry", "slicing" : { "discriminator" : [ { "type" : "profile", "path" : "reference" } ], "rules" : "open" }, "short" : "entry", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/Resource" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:vital_signs_section.entry:sliceentry", "path" : "Composition.section.entry", "sliceName" : "sliceEntry", "short" : "This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. ", "definition" : "A reference to the actual resource from which the narrative in the section is derived.", "comment" : "If there are no entries in the list, an emptyReason SHOULD be provided.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.entry", "min" : 0, "max" : "*" }, "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/StructureDefinition/vitalsigns" } ], "condition" : [ "cmp-2" ], "mapping" : [ { "identity" : "rim", "map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]" }, { "identity" : "cda", "map" : ".entry" } ] }, { "id" : "Composition.section:vital_signs_section.emptyReason", "path" : "Composition.section.emptyReason", "short" : "Why the section is empty", "definition" : "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.", "comment" : "The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.", "requirements" : "Allows capturing things like "none exist" or "not asked" which can be important for most lists.", "min" : 0, "max" : "1", "base" : { "path" : "Composition.section.emptyReason", "min" : 0, "max" : "1" }, "type" : [ { "code" : "CodeableConcept" } ], "condition" : [ "cmp-2" ], "binding" : { "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString" : "SectionEmptyReason" } ], "strength" : "preferred", "description" : "If a section is empty, why it is empty.", "valueSetReference" : { "reference" : "http://hl7.org/fhir/ValueSet/list-empty-reason" } }, "mapping" : [ { "identity" : "rim", "map" : ".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]" }, { "identity" : "cda", "map" : "n/a" } ] }, { "id" : "Composition.section:vital_signs_section.section", "path" : "Composition.section.section", "short" : "Nested Section", "definition" : "A nested sub-section within this section.", "comment" : "Nested sections are primarily used to help human readers navigate to particular portions of the document.", "min" : 0, "max" : "*", "base" : { "path" : "Composition.section.section", "min" : 0, "max" : "*" }, "contentReference" : "#Composition.section:vital_signs_section", "condition" : [ "cmp-1" ], "mapping" : [ { "identity" : "rim", "map" : "./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]" }, { "identity" : "cda", "map" : ".component.section" } ] } ] }, "differential" : { "element" : [ { "id" : "Composition", "path" : "Composition" }, { "id" : "Composition.type", "path" : "Composition.type", "short" : "type", "binding" : { "strength" : "required", "valueSetReference" : { "reference" : "http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.8.1" } } }, { "id" : "Composition.section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "slicing" : { "discriminator" : [ { "type" : "value", "path" : "code" } ], "rules" : "open" } }, { "id" : "Composition.section:assessment_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "assessment_section", "label" : "Assessment Section", "short" : "Assessment Section", "max" : "1" }, { "id" : "Composition.section:assessment_section.title", "path" : "Composition.section.title", "short" : "title", "min" : 1 }, { "id" : "Composition.section:assessment_section.code", "path" : "Composition.section.code", "label" : "Assessments", "short" : "Assessments", "min" : 1, "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "51848-0" } ] } }, { "id" : "Composition.section:assessment_section.text", "path" : "Composition.section.text", "short" : "This section contains only human readable content", "min" : 1 }, { "id" : "Composition.section:allergies_and_intolerances_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } ], "path" : "Composition.section", "sliceName" : "allergies_and_intolerances_section", "label" : "Allergies and Intolerances Section", "short" : "Allergies and Intolerances Section", "max" : "1" }, { "id" : "Composition.section:allergies_and_intolerances_section.title", "path" : "Composition.section.title", "short" : "title", "min" : 1 }, { "id" : "Composition.section:allergies_and_intolerances_section.code", "path" : "Composition.section.code", "label" : "Allergies, adverse reactions, alerts", "short" : "Allergies, adverse reactions, alerts", "min" : 1, "patternCodeableConcept" : { "coding" : [ { "system" : "http://loinc.org", "code" : "48765-2" } ] } }, { "id" : "Composition.section:allergies_and_intolerances_section.text", "path" : "Composition.section.text", "short" : "text", "min" : 1 }, { "id" : "Composition.section:allergies_and_intolerances_section.entry", "path" : "Composition.section.entry", "slicing" : { "discriminator" : [ { "type" : "profile", "path" : "reference" } ], "rules" : "open" }, "short" : "entry" }, { "id" : "Composition.section:allergies_and_intolerances_section.entry:sliceentry", "path" : "Composition.section.entry", "sliceName" : "sliceEntry", "type" : [ { "code" : "Reference", "targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance" } ] }, { "id" : "Composition.section:assessment_and_plan_section", "extension" : [ { "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name", "valueString" : "Section" } 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