Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Clinical Document | International Patient Summary composition | |
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
identifier | S | 0..1 | Identifier | Version-independent identifier for the Composition |
status | S | 1..1 | code | preliminary | final | amended | entered-in-error |
type | S | 1..1 | CodeableConceptIPS | Kind of composition ("Patient Summary") Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 60591-5 | |
subject | S | 1..1 | Reference(Patient (IPS)) | Who and/or what the composition is about |
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
encounter | 0..1 | Reference(Encounter) | Context of the Composition | |
date | S | 1..1 | dateTime | Composition editing time |
author | S | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the IPS |
title | S | 1..1 | string | International Patient Summary |
confidentiality | 0..1 | code | As defined by affinity domain | |
attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
mode | S | 1..1 | code | personal | professional | legal | official |
time | S | 0..1 | dateTime | When the composition was attested |
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
custodian | S | 0..1 | Reference(Organization) | Organization which maintains the composition |
relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |
code | 1..1 | code | replaces | transforms | signs | appends | |
target[x] | 1..1 | Target of the relationship | ||
targetIdentifier | Identifier | |||
targetReference | Reference(Composition | Composition (IPS)) | |||
Slices for event | 0..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by pattern:code | |
event:careProvisioningEvent | S | 0..1 | BackboneElement | The care provisioning being documented |
code | S | 1..1 | CodeableConcept | Code(s) that apply to the event being documented Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActClass | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: PCPR | |
period | S | 0..1 | Period | The period covered by the documentation |
Slices for section | S | 1..* | BackboneElement | Sections composing the IPS Slice: Unordered, Open by pattern:code |
section:All Slices | Content/Rules for all slices | |||
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
emptyReason | 0..0 | |||
section | 0..0 | |||
section:sectionMedications | S | 1..1 | BackboneElement | IPS Medication Summary Section |
title | S | 1..1 | string | Medication Summary section |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
Slices for entry | S | 1..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications relevant for the scope of the patient summary Slice: Unordered, Open by profile:resolve() |
entry:medicationStatement | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | |
entry:medicationRequest | 0..* | Reference(Medication Request (IPS)) | A reference to data that supports this section | |
section:sectionAllergies | S | 1..1 | BackboneElement | IPS Allergies and Intolerances Section |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
Slices for entry | S | 1..* | Reference(AllergyIntolerance | DocumentReference) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open by profile:resolve() |
entry:allergyOrIntolerance | S | 1..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section |
section:sectionProblems | S | 1..1 | BackboneElement | IPS Problems Section |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
Slices for entry | S | 1..* | Reference(Condition | DocumentReference) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open by profile:resolve() |
entry:problem | S | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section |
section:sectionProceduresHx | S | 0..1 | BackboneElement | IPS History of Procedures Section |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
Slices for entry | S | 1..* | Reference(Procedure | DocumentReference) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open by profile:resolve() |
entry:procedure | S | 1..* | Reference(Procedure (IPS)) | A reference to data that supports this section |
section:sectionImmunizations | S | 0..1 | BackboneElement | IPS Immunizations Section |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
Slices for entry | S | 1..* | Reference(Immunization | DocumentReference) | Patient's immunization status and pertinent history. Slice: Unordered, Open by profile:resolve() |
entry:immunization | S | 1..* | Reference(Immunization (IPS)) | A reference to data that supports this section |
section:sectionMedicalDevices | S | 0..1 | BackboneElement | IPS Medical Devices Section |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46264-8 | |
Slices for entry | S | 1..* | Reference(DeviceUseStatement | DocumentReference) | Patient history of medical device use. Slice: Unordered, Open by profile:resolve() |
entry:deviceStatement | S | 1..* | Reference(Device Use Statement (IPS)) | A reference to data that supports this section |
section:sectionResults | S | 0..1 | BackboneElement | IPS Results Section |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
Slices for entry | S | 1..* | Reference(Observation | DiagnosticReport | DocumentReference) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Slice: Unordered, Open by type:resolve(), profile:resolve() |
entry:results-observation | S | 0..* | Reference(Observation Results (IPS)) | A reference to data that supports this section |
entry:results-diagnosticReport | S | 0..* | Reference(DiagnosticReport (IPS)) | A reference to data that supports this section |
section:sectionVitalSigns | 0..1 | BackboneElement | IPS Vital Signs Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
Slices for entry | 0..* | Reference(Observation | DocumentReference) | Notable vital signs or physical findings. Slice: Unordered, Open by profile:resolve() | |
entry:vitalSign | 0..* | Reference(Vital Signs Profile) | A reference to data that supports this section | |
section:sectionPastIllnessHx | 0..1 | BackboneElement | IPS History of Past Illness Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
Slices for entry | 1..* | Reference(Condition | DocumentReference) | Conditions the patient suffered in the past. Slice: Unordered, Open by profile:resolve() | |
entry:pastProblem | 1..* | Reference(Condition (IPS)) | A reference to data that supports this section | |
section:sectionFunctionalStatus | 0..1 | BackboneElement | IPS Functional Status | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47420-5 | |
Slices for entry | 0..* | Reference(Condition | ClinicalImpression | DocumentReference) | Optional entry used to represent disabilities and functional assessments Slice: Unordered, Open by profile:resolve() | |
entry:disability | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section | |
entry:functionalAssessment | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section | |
section:sectionPlanOfCare | 0..1 | BackboneElement | IPS Plan of Care Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
Slices for entry | 0..* | Reference(CarePlan | DocumentReference) | Optional entry used to represent structured care plans Slice: Unordered, Open by profile:resolve() | |
entry:carePlan | 0..* | Reference(CarePlan) | A reference to data that supports this section | |
section:sectionSocialHistory | 0..1 | BackboneElement | IPS Social History Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
Slices for entry | 0..* | Reference(Observation | DocumentReference) | Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) Slice: Unordered, Open by profile:resolve() | |
entry:smokingTobaccoUse | 0..1 | Reference(Observation - SH: tobacco use) | A reference to data that supports this section | |
entry:alcoholUse | 0..1 | Reference(Observation - SH: alcohol use) | A reference to data that supports this section | |
section:sectionPregnancyHx | 0..1 | BackboneElement | IPS History of Pregnancy Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
Slices for entry | 0..* | Reference(Observation | DocumentReference) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. Slice: Unordered, Open by profile:resolve() | |
entry:pregnancyStatus | 0..* | Reference(Observation - Pregnancy: status) | A reference to data that supports this section | |
entry:pregnancyOutcomeSummary | 0..* | Reference(Observation - Pregnancy: outcome) | A reference to data that supports this section | |
section:sectionAdvanceDirectives | 0..1 | BackboneElement | IPS Advance Directives Section | |
title | 1..1 | string | Label for section (e.g. for ToC) | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 42348-3 | |
Slices for entry | 0..* | Reference(Consent | DocumentReference) | Narrative description of the patient's advance directive. Slice: Unordered, Open by profile:resolve() | |
entry:advanceDirectivesConsent | 0..* | Reference(Consent) | A reference to data that supports this section | |
Documentation for this format |