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This page is part of the C-CDA on FHIR Implementation Guide (v1.8.0: STU 1 Ballot 2) based on FHIR v1.8.0. 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-History-and-Physical",
"text" : {
"status" : "generated",
"div" : "<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>url</b>: <a href="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-History-and-Physical">http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-History-and-Physical</a></p><p><b>name</b>: C-CDA on FHIR History and Physical</p><p><b>status</b>: DRAFT</p><p><b>date</b>: 08/12/2016 6:39:19 AM</p><p><b>publisher</b>: Lantana Consulting Group</p><p><b>contact</b>: </p><p><b>description</b>: A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.
The first portion of the report is a current collection of organized information unique to an individual. This is typically supplied by the patient or the caregiver, concerning the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members.
The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures.
The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues.
A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P note.</p><p><b>url</b>: <a href="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-History-and-Physical">http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-History-and-Physical</a></p><p><b>name</b>: C-CDA on FHIR History and Physical</p><p><b>status</b>: DRAFT</p><p><b>publisher</b>: Lantana Consulting Group</p><p><b>contact</b>: </p><p><b>date</b>: 08/12/2016 6:39:19 AM</p><p><b>description</b>: A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.
The first portion of the report is a current collection of organized information unique to an individual. This is typically supplied by the patient or the caregiver, concerning the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members.
The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures.
The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues.
A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P note.</p><blockquote><p><b>mapping</b></p><p><b>identity</b>: rim</p><p><b>uri</b>: <a href="http://hl7.org/v3">http://hl7.org/v3</a></p><p><b>name</b>: RIM Mapping</p></blockquote><blockquote><p><b>mapping</b></p><p><b>identity</b>: cda</p><p><b>uri</b>: <a href="http://hl7.org/v3/cda">http://hl7.org/v3/cda</a></p><p><b>name</b>: CDA (R2)</p></blockquote><blockquote><p><b>mapping</b></p><p><b>identity</b>: w5</p><p><b>uri</b>: <a href="http://hl7.org/fhir/w5">http://hl7.org/fhir/w5</a></p><p><b>name</b>: W5 Mapping</p></blockquote><p><b>kind</b>: RESOURCE</p><p><b>abstract</b>: false</p><p><b>contextType</b>: RESOURCE</p><p><b>context</b>: Composition</p><p><b>type</b>: Composition</p><p><b>baseDefinition</b>: <a href="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-US-Realm-Header">http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-US-Realm-Header</a></p><p><b>derivation</b>: CONSTRAINT</p><h3>Snapshots</h3><table class="grid"><tr><td>-</td><td><b>Element</b></td></tr><tr><td>*</td><td>todo-bundle</td></tr></table><h3>Differentials</h3><table class="grid"><tr><td>-</td><td><b>Element</b></td></tr><tr><td>*</td><td>todo-bundle</td></tr></table></div>"
},
"url" : "http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-History-and-Physical",
"name" : "C-CDA on FHIR History and Physical",
"status" : "draft",
"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"
}
]
}
],
"date" : "2016-12-08T06:39:19+11:00",
"description" : "A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.
The first portion of the report is a current collection of organized information unique to an individual. This is typically supplied by the patient or the caregiver, concerning the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members.
The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures.
The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues.
A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P note.",
"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/ccda/StructureDefinition/CCDA-on-FHIR-US-Realm-Header",
"derivation" : "constraint",
"snapshot" : {
"element" : [
{
"id" : "Composition:c-cdaonfhirhistoryandphysical",
"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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.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:c-cdaonfhirhistoryandphysical.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.",
"comments" : "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 as much as possible.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Resource.implicitRules",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "uri"
}
],
"isModifier" : true,
"isSummary" : true
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.language",
"path" : "Composition.language",
"short" : "language",
"definition" : "SHALL contain exactly one [1..1] language (CONF:2219-146).",
"comments" : "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"
}
}
],
"strength" : "extensible",
"description" : "A human language.",
"valueSetReference" : {
"reference" : "http://hl7.org/fhir/ValueSet/languages"
}
}
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.extension",
"path" : "Composition.extension",
"slicing" : {
"discriminator" : [
"Composition.url"
],
"rules" : "open"
},
"short" : "Extension",
"definition" : "MAY contain zero or more [0..*] C-CDA on FHIR Authorization (identifier: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization) (CONF:2219-2012).",
"min" : 0,
"max" : "*",
"base" : {
"path" : "DomainResource.extension",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Extension"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.extension:extension_slice_pos2",
"path" : "Composition.extension",
"sliceName" : "extension_slice_pos2",
"label" : "dataEnterer",
"short" : "dataEnterer",
"definition" : "MAY contain zero or one [0..1] C-CDA on FHIR Data Enterer (identifier: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer) (CONF:2219-1844).",
"min" : 0,
"max" : "1",
"base" : {
"path" : "DomainResource.extension",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Extension",
"profile" : "http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.extension:extension_slice_pos3",
"path" : "Composition.extension",
"sliceName" : "extension_slice_pos3",
"label" : "informant",
"short" : "informant",
"definition" : "MAY contain zero or more [0..*] C-CDA on FHIR Informant (identifier: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Informant) (CONF:2219-1849).",
"min" : 0,
"max" : "*",
"base" : {
"path" : "DomainResource.extension",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Extension",
"profile" : "http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Informant"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.extension:extension_slice_pos4",
"path" : "Composition.extension",
"sliceName" : "extension_slice_pos4",
"label" : "informationRecipient",
"short" : "informationRecipient",
"definition" : "MAY contain zero or more [0..*] C-CDA on FHIR Information Recipient (identifier: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient) (CONF:2219-1856).",
"min" : 0,
"max" : "*",
"base" : {
"path" : "DomainResource.extension",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Extension",
"profile" : "http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.extension:extension_slice_pos5",
"path" : "Composition.extension",
"sliceName" : "extension_slice_pos5",
"label" : "participant",
"short" : "participant",
"definition" : "MAY contain zero or more [0..*] C-CDA on FHIR Participant (identifier: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Participant) (CONF:2219-1861).",
"min" : 0,
"max" : "*",
"base" : {
"path" : "DomainResource.extension",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Extension",
"profile" : "http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Participant"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.extension:extension_slice_pos6",
"path" : "Composition.extension",
"sliceName" : "extension_slice_pos6",
"label" : "performer",
"short" : "performer",
"definition" : "SHOULD contain zero or more [0..*] C-CDA on FHIR Performer (identifier: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Performer) (CONF:2219-1869).",
"min" : 0,
"max" : "*",
"base" : {
"path" : "DomainResource.extension",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Extension",
"profile" : "http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Performer"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.extension:extension_slice_pos7",
"path" : "Composition.extension",
"sliceName" : "extension_slice_pos7",
"label" : "authorization",
"short" : "authorization",
"definition" : "MAY contain zero or more [0..*] C-CDA on FHIR Authorization (identifier: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization) (CONF:2219-2012).",
"min" : 0,
"max" : "*",
"base" : {
"path" : "DomainResource.extension",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Extension",
"profile" : "http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.identifier",
"path" : "Composition.identifier",
"short" : "identifier",
"definition" : "SHALL contain exactly one [1..1] identifier (CONF:2219-147).",
"comments" : "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:c-cdaonfhirhistoryandphysical.date",
"path" : "Composition.date",
"short" : "date",
"definition" : "SHALL contain exactly one [1..1] date (CONF:2219-148).",
"comments" : "US Realm Datetime",
"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:c-cdaonfhirhistoryandphysical.type",
"path" : "Composition.type",
"label" : "History and Physical",
"short" : "History and Physical",
"definition" : "SHALL contain exactly one [1..1] type, which SHALL be selected from ValueSet HPDocumentType http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.1.11.20.22 DYNAMIC (CONF:2219-1820).",
"comments" : "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/ccda/ValueSet/2.16.840.1.113883.1.11.20.22",
"display" : "HPDocumentType"
}
},
"mapping" : [
{
"identity" : "rim",
"map" : "./code"
},
{
"identity" : "cda",
"map" : ".code"
},
{
"identity" : "w5",
"map" : "class"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.title",
"path" : "Composition.title",
"label" : "Document Title",
"short" : "Document Title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-150).",
"comments" : "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:c-cdaonfhirhistoryandphysical.status",
"path" : "Composition.status",
"short" : "status",
"definition" : "SHALL contain exactly one [1..1] status (CONF:2219-1048).",
"comments" : "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 "withdrawn" 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" : {
"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:c-cdaonfhirhistoryandphysical.confidentiality",
"path" : "Composition.confidentiality",
"short" : "confidentiality",
"definition" : "SHALL contain exactly one [1..1] confidentiality, which SHALL be selected from ValueSet v3-ConfidentialityClassification http://hl7.org/fhir/ValueSet/v3-ConfidentialityClassification STATIC 2016-01-01 (CONF:2219-151).",
"comments" : "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).",
"min" : 1,
"max" : "1",
"base" : {
"path" : "Composition.confidentiality",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "code"
}
],
"isModifier" : true,
"isSummary" : true,
"binding" : {
"strength" : "required",
"valueSetReference" : {
"reference" : "http://hl7.org/fhir/ValueSet/v3-ConfidentialityClassification",
"display" : "v3-ConfidentialityClassification"
}
},
"mapping" : [
{
"identity" : "rim",
"map" : ".confidentialityCode"
},
{
"identity" : "cda",
"map" : ".confidentialityCode"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.subject",
"path" : "Composition.subject",
"label" : "recordTarget",
"short" : "recordTarget",
"definition" : "SHALL contain exactly one [1..1] U.S. Core Patient Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient) (CONF:2219-152).",
"comments" : "U.S. DAF 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"
}
],
"isSummary" : true,
"mapping" : [
{
"identity" : "rim",
"map" : ".participation[typeCode="SBJ"].role[typeCode="PAT"]"
},
{
"identity" : "cda",
"map" : ".recordTarget"
},
{
"identity" : "w5",
"map" : "who.focus"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.author",
"path" : "Composition.author",
"label" : "author",
"short" : "author",
"definition" : "SHALL contain at least one [1..*] U.S. Core Practitioner Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-pract) (CONF:2219-153).",
"comments" : "U.S. DAF Practitioner",
"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-pract"
},
{
"code" : "Reference",
"targetProfile" : "http://hl7.org/fhir/StructureDefinition/Device"
}
],
"isSummary" : true,
"mapping" : [
{
"identity" : "rim",
"map" : ".participation[typeCode="AUT"].role[classCode="ASSIGNED"]"
},
{
"identity" : "cda",
"map" : ".author.assignedAuthor"
},
{
"identity" : "w5",
"map" : "who.author"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.attester",
"path" : "Composition.attester",
"slicing" : {
"discriminator" : [
"Composition.attester.mode"
],
"rules" : "open"
},
"short" : "Attests to accuracy of composition",
"definition" : "MAY contain zero or more [0..*] attester (CONF:2219-2083) such that it",
"comments" : "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" : "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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16",
"path" : "Composition.attester",
"sliceName" : "attester_slice_pos16",
"short" : "attester",
"definition" : "SHOULD contain zero or one [0..1] attester (CONF:2219-2082) such that it",
"comments" : "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" : "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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16.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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16.mode:attester_slice_pos16",
"path" : "Composition.attester.mode",
"sliceName" : "attester_slice_pos16",
"short" : "mode",
"definition" : "SHALL contain exactly one [1..1] mode="legal" (CodeSystem: FHIR CompositionAttestationMode http://hl7.org/fhir/composition-attestation-mode) (CONF:2219-2084).",
"comments" : "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"
}
],
"patternString" : "legal",
"isSummary" : true,
"binding" : {
"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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16.time",
"path" : "Composition.attester.time",
"short" : "When composition attested",
"definition" : "When 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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16.party:attester_slice_pos16",
"path" : "Composition.attester.party",
"sliceName" : "attester_slice_pos16",
"short" : "party",
"definition" : "MAY contain zero or one [0..1] U.S. Core Practitioner Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-pract) (CONF:2219-2085).",
"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/us/core/StructureDefinition/us-core-pract"
}
],
"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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17",
"path" : "Composition.attester",
"sliceName" : "attester_slice_pos17",
"short" : "attester",
"definition" : "MAY contain zero or more [0..*] attester (CONF:2219-2083) such that it",
"comments" : "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" : "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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17.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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17.mode:attester_slice_pos17",
"path" : "Composition.attester.mode",
"sliceName" : "attester_slice_pos17",
"short" : "mode",
"definition" : "SHALL contain at least one [1..*] mode (CONF:2219-2086).",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17.time",
"path" : "Composition.attester.time",
"short" : "When composition attested",
"definition" : "When 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:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17.party:attester_slice_pos17",
"path" : "Composition.attester.party",
"sliceName" : "attester_slice_pos17",
"short" : "party",
"definition" : "MAY contain zero or one [0..1] U.S. Core Practitioner Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-pract) (CONF:2219-2087).",
"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/us/core/StructureDefinition/us-core-pract"
}
],
"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:c-cdaonfhirhistoryandphysical.custodian",
"path" : "Composition.custodian",
"label" : "custodian",
"short" : "custodian",
"definition" : "SHALL contain exactly one [1..1] U.S. Core Organization Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization) (CONF:2219-154).",
"comments" : "U.S. DAF Organization",
"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:c-cdaonfhirhistoryandphysical.event",
"path" : "Composition.event",
"short" : "The clinical service(s) being documented",
"definition" : "The clinical service, such as a colonoscopy or an appendectomy, being documented.",
"comments" : "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" : "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:c-cdaonfhirhistoryandphysical.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:c-cdaonfhirhistoryandphysical.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.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:c-cdaonfhirhistoryandphysical.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:c-cdaonfhirhistoryandphysical.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:c-cdaonfhirhistoryandphysical.section",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"slicing" : {
"discriminator" : [
"Composition.section.code"
],
"rules" : "open"
},
"short" : "Composition is broken into sections",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1759) such that it",
"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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos2",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos2",
"label" : "Allergies and Intolerances Section",
"short" : "Allergies and Intolerances Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1739) such that it",
"comments" : "Allergies and Intolerances Section",
"min" : 1,
"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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.title:section_slice_pos2",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos2",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1760).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.code:section_slice_pos2",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos2",
"label" : "Allergies, adverse reactions, alerts",
"short" : "Allergies, adverse reactions, alerts",
"definition" : "SHALL contain exactly one [1..1] code="48765-2" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1761).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "48765-2"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.text:section_slice_pos2",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos2",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1762).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.entry:section_slice_pos2",
"path" : "Composition.section.entry",
"sliceName" : "section_slice_pos2",
"short" : "entry",
"definition" : "MAY contain zero or more [0..*] U.S. Core AllergyIntolerance Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance) (CONF:2219-2453).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos2",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos3",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos3",
"label" : "Assessment and Plan Section",
"short" : "Assessment and Plan Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1740) such that it",
"comments" : "Assessment and Plan 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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.title:section_slice_pos3",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos3",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1763).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.code:section_slice_pos3",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos3",
"label" : "Assessment and Plan",
"short" : "Assessment and Plan",
"definition" : "SHALL contain exactly one [1..1] code="51847-2" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1764).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "51847-2"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.text:section_slice_pos3",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos3",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1765).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos3",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos4",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos4",
"label" : "Assessment Section",
"short" : "Assessment Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1741) such that it",
"comments" : "Assessment 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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.title:section_slice_pos4",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos4",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1766).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.code:section_slice_pos4",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos4",
"label" : "Assessments",
"short" : "Assessments",
"definition" : "SHALL contain exactly one [1..1] code="51848-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1767).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "51848-0"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.text:section_slice_pos4",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos4",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1768).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos4",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos5",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos5",
"label" : "Chief Complaint and Reason for Visit Section",
"short" : "Chief Complaint and Reason for Visit Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1742) such that it",
"comments" : "Chief Complaint and Reason for Visit 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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.title:section_slice_pos5",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos5",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1769).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.code:section_slice_pos5",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos5",
"label" : "Chief Complaint and Reason for Visit",
"short" : "Chief Complaint and Reason for Visit",
"definition" : "SHALL contain exactly one [1..1] code="46239-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1770).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "46239-0"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.text:section_slice_pos5",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos5",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1771).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos5",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos6",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos6",
"label" : "Chief Complaint Section",
"short" : "Chief Complaint Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1743) such that it",
"comments" : "Chief Complaint 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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.title:section_slice_pos6",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos6",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1772).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.code:section_slice_pos6",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos6",
"label" : "Chief Complaint",
"short" : "Chief Complaint",
"definition" : "SHALL contain exactly one [1..1] code="10154-3" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1773).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "10154-3"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.text:section_slice_pos6",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos6",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1774).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos6",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos7",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos7",
"label" : "Family History Section",
"short" : "Family History Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1744) such that it",
"comments" : "Family History Section",
"min" : 1,
"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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.title:section_slice_pos7",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos7",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1775).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.code:section_slice_pos7",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos7",
"label" : "Family History",
"short" : "Family History",
"definition" : "SHALL contain exactly one [1..1] code="10157-6" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1776).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "10157-6"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.text:section_slice_pos7",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos7",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1777).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.entry:section_slice_pos7",
"path" : "Composition.section.entry",
"sliceName" : "section_slice_pos7",
"short" : "entry",
"definition" : "MAY contain zero or more [0..*] FamilyMemberHistory (identifier: http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory) (CONF:2219-2454).",
"comments" : "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",
"profile" : "http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory"
}
],
"condition" : [
"cmp-2"
],
"mapping" : [
{
"identity" : "rim",
"map" : "Entity. Role, or Act"
},
{
"identity" : "v2",
"map" : "Not in scope for v2"
},
{
"identity" : "rim",
"map" : "Observation[classCode=OBS, moodCode=EVN]"
},
{
"identity" : "w5",
"map" : "clinical.general"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos7",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos8",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos8",
"label" : "General Status Section",
"short" : "General Status Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1745) such that it",
"comments" : "General Status Section",
"min" : 1,
"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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.title:section_slice_pos8",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos8",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1778).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.code:section_slice_pos8",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos8",
"label" : "General Status",
"short" : "General Status",
"definition" : "SHALL contain exactly one [1..1] code="10210-3" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1779).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "10210-3"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.text:section_slice_pos8",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos8",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1780).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos8",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos9",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos9",
"label" : "History of Past Illness Section",
"short" : "History of Past Illness Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1746) such that it",
"comments" : "History of Past Illness Section",
"min" : 1,
"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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.title:section_slice_pos9",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos9",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1781).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.code:section_slice_pos9",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos9",
"label" : "History of Past Illness",
"short" : "History of Past Illness",
"definition" : "SHALL contain exactly one [1..1] code="11348-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1782).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "11348-0"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.text:section_slice_pos9",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos9",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1783).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.entry:section_slice_pos9",
"path" : "Composition.section.entry",
"sliceName" : "section_slice_pos9",
"short" : "entry",
"definition" : "MAY contain zero or more [0..*] U.S. Core Condition Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition) (CONF:2219-2455).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos9",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos10",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos10",
"label" : "History of Present Illness Section",
"short" : "History of Present Illness Section",
"definition" : "SHOULD contain zero or one [0..1] section (CONF:2219-1747) such that it",
"comments" : "History of Present Illness 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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.title:section_slice_pos10",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos10",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1784).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.code:section_slice_pos10",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos10",
"label" : "History of Present Illness",
"short" : "History of Present Illness",
"definition" : "SHALL contain exactly one [1..1] code="10164-2" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1785).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "10164-2"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.text:section_slice_pos10",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos10",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1786).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos10",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos11",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos11",
"label" : "Immunizations Section",
"short" : "Immunizations Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1748) such that it",
"comments" : "Immunizations 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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.title:section_slice_pos11",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos11",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1787).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.code:section_slice_pos11",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos11",
"label" : "Immunizations",
"short" : "Immunizations",
"definition" : "SHALL contain exactly one [1..1] code="11369-6" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1788).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "11369-6"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.text:section_slice_pos11",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos11",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1789).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.entry:section_slice_pos11",
"path" : "Composition.section.entry",
"sliceName" : "section_slice_pos11",
"short" : "entry",
"definition" : "SHOULD contain zero or more [0..*] U.S. Core Immunization Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization) (CONF:2219-2456).",
"comments" : "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-immunization"
}
],
"condition" : [
"cmp-2"
],
"mapping" : [
{
"identity" : "rim",
"map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"
},
{
"identity" : "cda",
"map" : ".entry"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos11",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos12",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos12",
"label" : "Medications Section",
"short" : "Medications Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1749) such that it",
"comments" : "Medications Section",
"min" : 1,
"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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.title:section_slice_pos12",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos12",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1790).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.code:section_slice_pos12",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos12",
"label" : "History of medication use",
"short" : "History of medication use",
"definition" : "SHALL contain exactly one [1..1] code="10160-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1791).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "10160-0"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.text:section_slice_pos12",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos12",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1792).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.entry:section_slice_pos12",
"path" : "Composition.section.entry",
"sliceName" : "section_slice_pos12",
"short" : "entry",
"definition" : "SHOULD contain zero or more [0..*] U.S. Core MedicationStatement Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationstatement) (CONF:2219-2457).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos12",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos13",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos13",
"label" : "Physical Exam Section",
"short" : "Physical Exam Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1750) such that it",
"comments" : "Physical Exam Section",
"min" : 1,
"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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.title:section_slice_pos13",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos13",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1793).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.code:section_slice_pos13",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos13",
"label" : "Physical Findings",
"short" : "Physical Findings",
"definition" : "SHALL contain exactly one [1..1] code="29545-1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1794).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "29545-1"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.text:section_slice_pos13",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos13",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1795).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos13",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos14",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos14",
"label" : "Plan of Treatment Section",
"short" : "Plan of Treatment Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1751) such that it",
"comments" : "Plan of Treatment 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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.title:section_slice_pos14",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos14",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1796).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.code:section_slice_pos14",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos14",
"label" : "Plan of Treatment",
"short" : "Plan of Treatment",
"definition" : "SHALL contain exactly one [1..1] code="18776-5" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1797).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "18776-5"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.text:section_slice_pos14",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos14",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1798).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos14",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos15",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos15",
"label" : "Problem Section",
"short" : "Problem Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1752) such that it",
"comments" : "Problem 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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.title:section_slice_pos15",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos15",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1799).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.code:section_slice_pos15",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos15",
"label" : "Problem List",
"short" : "Problem List",
"definition" : "SHALL contain exactly one [1..1] code="11450-4" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1800).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "11450-4"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.text:section_slice_pos15",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos15",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1801).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.entry:section_slice_pos15",
"path" : "Composition.section.entry",
"sliceName" : "section_slice_pos15",
"short" : "entry",
"definition" : "SHOULD contain zero or more [0..*] U.S. Core Condition Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition) (CONF:2219-2458).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos15",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos16",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos16",
"label" : "Procedures Section",
"short" : "Procedures Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1753) such that it",
"comments" : "Procedures 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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.title:section_slice_pos16",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos16",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1802).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.code:section_slice_pos16",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos16",
"label" : "History of Procedures",
"short" : "History of Procedures",
"definition" : "SHALL contain exactly one [1..1] code="47519-4" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1803).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "47519-4"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.text:section_slice_pos16",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos16",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1804).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.entry:section_slice_pos16",
"path" : "Composition.section.entry",
"sliceName" : "section_slice_pos16",
"short" : "entry",
"definition" : "MAY contain zero or more [0..*] U.S. Core Procedure Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure) (CONF:2219-2459).",
"comments" : "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-procedure"
}
],
"condition" : [
"cmp-2"
],
"mapping" : [
{
"identity" : "rim",
"map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"
},
{
"identity" : "cda",
"map" : ".entry"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos16",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos17",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos17",
"label" : "Reason for Visit Section",
"short" : "Reason for Visit Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1754) such that it",
"comments" : "Reason for Visit 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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.title:section_slice_pos17",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos17",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1805).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.code:section_slice_pos17",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos17",
"label" : "Reason for Visit",
"short" : "Reason for Visit",
"definition" : "SHALL contain exactly one [1..1] code="29299-5" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1806).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "29299-5"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.text:section_slice_pos17",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos17",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1807).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos17",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos18",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos18",
"label" : "Results Section",
"short" : "Results Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1755) such that it",
"comments" : "Results Section",
"min" : 1,
"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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.title:section_slice_pos18",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos18",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1808).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.code:section_slice_pos18",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos18",
"label" : "Relevant diagnostic tests and/or laboratory data",
"short" : "Relevant diagnostic tests and/or laboratory data",
"definition" : "SHALL contain exactly one [1..1] code="30954-2" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1809).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "30954-2"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.text:section_slice_pos18",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos18",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1810).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos18",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos19",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos19",
"label" : "Review of Systems Section",
"short" : "Review of Systems Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1756) such that it",
"comments" : "Review of Systems Section",
"min" : 1,
"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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.title:section_slice_pos19",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos19",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1811).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.code:section_slice_pos19",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos19",
"label" : "Review of Systems",
"short" : "Review of Systems",
"definition" : "SHALL contain exactly one [1..1] code="10187-3" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1812).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "10187-3"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.text:section_slice_pos19",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos19",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1813).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos19",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos20",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos20",
"label" : "Social History Section",
"short" : "Social History Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1757) such that it",
"comments" : "Social History Section",
"min" : 1,
"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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.title:section_slice_pos20",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos20",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1814).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.code:section_slice_pos20",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos20",
"label" : "Social History",
"short" : "Social History",
"definition" : "SHALL contain exactly one [1..1] code="29762-2" (CONF:2219-1815).",
"comments" : "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" : [
{
"code" : "29762-2"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.text:section_slice_pos20",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos20",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1816).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.entry:section_slice_pos20",
"path" : "Composition.section.entry",
"sliceName" : "section_slice_pos20",
"short" : "entry",
"definition" : "MAY contain zero or more [0..*] U.S. Core SmokingStatus Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus) (CONF:2219-2461).",
"comments" : "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-smokingstatus"
}
],
"condition" : [
"cmp-2"
],
"mapping" : [
{
"identity" : "rim",
"map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"
},
{
"identity" : "cda",
"map" : ".entry"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos20",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos21",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos21",
"label" : "Vital Signs Section",
"short" : "Vital Signs Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1758) such that it",
"comments" : "Vital Signs Section",
"min" : 1,
"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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.title:section_slice_pos21",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos21",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1817).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.code:section_slice_pos21",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos21",
"label" : "Vital Signs",
"short" : "Vital Signs",
"definition" : "SHALL contain exactly one [1..1] code="8716-3" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1818).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "8716-3"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.text:section_slice_pos21",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos21",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1819).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.entry:section_slice_pos21",
"path" : "Composition.section.entry",
"sliceName" : "section_slice_pos21",
"short" : "entry",
"definition" : "SHOULD contain zero or more [0..*] U.S. Core VitalSigns Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-vitalsigns) (CONF:2219-2462).",
"comments" : "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-vitalsigns"
}
],
"condition" : [
"cmp-2"
],
"mapping" : [
{
"identity" : "rim",
"map" : ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"
},
{
"identity" : "cda",
"map" : ".entry"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos21",
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos22",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString" : "Section"
}
],
"path" : "Composition.section",
"sliceName" : "section_slice_pos22",
"label" : "Instructions Section",
"short" : "Instructions Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1759) such that it",
"comments" : "Instructions 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" : "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:c-cdaonfhirusrealmheader.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:c-cdaonfhirusrealmheader.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.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:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.title:section_slice_pos22",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos22",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1821).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.code:section_slice_pos22",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos22",
"label" : "Instructions",
"short" : "Instructions",
"definition" : "SHALL contain exactly one [1..1] code="69730-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1822).",
"comments" : "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" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "69730-0"
}
]
},
"binding" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.text:section_slice_pos22",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos22",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1823).",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.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.",
"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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.orderedBy",
"path" : "Composition.section.orderedBy",
"short" : "Order of section entries",
"definition" : "Specifies the order applied to the items in the section entries.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.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.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.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.",
"comments" : "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" : {
"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:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.section",
"path" : "Composition.section.section",
"short" : "Nested Section",
"definition" : "A nested sub-section within this section.",
"comments" : "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:c-cdaonfhirhistoryandphysical.section:section_slice_pos22",
"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:c-cdaonfhirhistoryandphysical",
"path" : "Composition"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.type",
"path" : "Composition.type",
"label" : "History and Physical",
"short" : "History and Physical",
"definition" : "SHALL contain exactly one [1..1] type, which SHALL be selected from ValueSet HPDocumentType http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.1.11.20.22 DYNAMIC (CONF:2219-1820).",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "CodeableConcept"
}
],
"binding" : {
"strength" : "required",
"valueSetReference" : {
"reference" : "http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.1.11.20.22",
"display" : "HPDocumentType"
}
}
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section",
"path" : "Composition.section",
"slicing" : {
"discriminator" : [
"Composition.section.code"
],
"rules" : "open"
},
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1759) such that it"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2",
"path" : "Composition.section",
"sliceName" : "section_slice_pos2",
"label" : "Allergies and Intolerances Section",
"short" : "Allergies and Intolerances Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1739) such that it",
"comments" : "Allergies and Intolerances Section",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.title:section_slice_pos2",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos2",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1760).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.code:section_slice_pos2",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos2",
"label" : "Allergies, adverse reactions, alerts",
"short" : "Allergies, adverse reactions, alerts",
"definition" : "SHALL contain exactly one [1..1] code="48765-2" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1761).",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "CodeableConcept"
}
],
"patternCodeableConcept" : {
"coding" : [
{
"system" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "48765-2"
}
]
}
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.text:section_slice_pos2",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos2",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1762).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.entry:section_slice_pos2",
"path" : "Composition.section.entry",
"sliceName" : "section_slice_pos2",
"short" : "entry",
"definition" : "MAY contain zero or more [0..*] U.S. Core AllergyIntolerance Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance) (CONF:2219-2453).",
"min" : 0,
"max" : "*",
"type" : [
{
"code" : "Reference",
"targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3",
"path" : "Composition.section",
"sliceName" : "section_slice_pos3",
"label" : "Assessment and Plan Section",
"short" : "Assessment and Plan Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1740) such that it",
"comments" : "Assessment and Plan Section",
"min" : 0,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.title:section_slice_pos3",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos3",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1763).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.code:section_slice_pos3",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos3",
"label" : "Assessment and Plan",
"short" : "Assessment and Plan",
"definition" : "SHALL contain exactly one [1..1] code="51847-2" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1764).",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "CodeableConcept"
}
],
"patternCodeableConcept" : {
"coding" : [
{
"system" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "51847-2"
}
]
}
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.text:section_slice_pos3",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos3",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1765).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4",
"path" : "Composition.section",
"sliceName" : "section_slice_pos4",
"label" : "Assessment Section",
"short" : "Assessment Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1741) such that it",
"comments" : "Assessment Section",
"min" : 0,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.title:section_slice_pos4",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos4",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1766).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.code:section_slice_pos4",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos4",
"label" : "Assessments",
"short" : "Assessments",
"definition" : "SHALL contain exactly one [1..1] code="51848-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1767).",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "CodeableConcept"
}
],
"patternCodeableConcept" : {
"coding" : [
{
"system" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "51848-0"
}
]
}
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.text:section_slice_pos4",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos4",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1768).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5",
"path" : "Composition.section",
"sliceName" : "section_slice_pos5",
"label" : "Chief Complaint and Reason for Visit Section",
"short" : "Chief Complaint and Reason for Visit Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1742) such that it",
"comments" : "Chief Complaint and Reason for Visit Section",
"min" : 0,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.title:section_slice_pos5",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos5",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1769).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.code:section_slice_pos5",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos5",
"label" : "Chief Complaint and Reason for Visit",
"short" : "Chief Complaint and Reason for Visit",
"definition" : "SHALL contain exactly one [1..1] code="46239-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1770).",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "CodeableConcept"
}
],
"patternCodeableConcept" : {
"coding" : [
{
"system" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "46239-0"
}
]
}
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.text:section_slice_pos5",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos5",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1771).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6",
"path" : "Composition.section",
"sliceName" : "section_slice_pos6",
"label" : "Chief Complaint Section",
"short" : "Chief Complaint Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1743) such that it",
"comments" : "Chief Complaint Section",
"min" : 0,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.title:section_slice_pos6",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos6",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1772).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.code:section_slice_pos6",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos6",
"label" : "Chief Complaint",
"short" : "Chief Complaint",
"definition" : "SHALL contain exactly one [1..1] code="10154-3" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1773).",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "CodeableConcept"
}
],
"patternCodeableConcept" : {
"coding" : [
{
"system" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "10154-3"
}
]
}
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.text:section_slice_pos6",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos6",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1774).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7",
"path" : "Composition.section",
"sliceName" : "section_slice_pos7",
"label" : "Family History Section",
"short" : "Family History Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1744) such that it",
"comments" : "Family History Section",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.title:section_slice_pos7",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos7",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1775).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.code:section_slice_pos7",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos7",
"label" : "Family History",
"short" : "Family History",
"definition" : "SHALL contain exactly one [1..1] code="10157-6" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1776).",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "CodeableConcept"
}
],
"patternCodeableConcept" : {
"coding" : [
{
"system" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "10157-6"
}
]
}
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.text:section_slice_pos7",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos7",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1777).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.entry:section_slice_pos7",
"path" : "Composition.section.entry",
"sliceName" : "section_slice_pos7",
"short" : "entry",
"definition" : "MAY contain zero or more [0..*] FamilyMemberHistory (identifier: http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory) (CONF:2219-2454).",
"min" : 0,
"max" : "*",
"type" : [
{
"code" : "Reference",
"profile" : "http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8",
"path" : "Composition.section",
"sliceName" : "section_slice_pos8",
"label" : "General Status Section",
"short" : "General Status Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1745) such that it",
"comments" : "General Status Section",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.title:section_slice_pos8",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos8",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1778).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.code:section_slice_pos8",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos8",
"label" : "General Status",
"short" : "General Status",
"definition" : "SHALL contain exactly one [1..1] code="10210-3" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1779).",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "CodeableConcept"
}
],
"patternCodeableConcept" : {
"coding" : [
{
"system" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "10210-3"
}
]
}
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.text:section_slice_pos8",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos8",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1780).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9",
"path" : "Composition.section",
"sliceName" : "section_slice_pos9",
"label" : "History of Past Illness Section",
"short" : "History of Past Illness Section",
"definition" : "SHALL contain exactly one [1..1] section (CONF:2219-1746) such that it",
"comments" : "History of Past Illness Section",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.title:section_slice_pos9",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos9",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1781).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.code:section_slice_pos9",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos9",
"label" : "History of Past Illness",
"short" : "History of Past Illness",
"definition" : "SHALL contain exactly one [1..1] code="11348-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1782).",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "CodeableConcept"
}
],
"patternCodeableConcept" : {
"coding" : [
{
"system" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "11348-0"
}
]
}
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.text:section_slice_pos9",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos9",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1783).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.entry:section_slice_pos9",
"path" : "Composition.section.entry",
"sliceName" : "section_slice_pos9",
"short" : "entry",
"definition" : "MAY contain zero or more [0..*] U.S. Core Condition Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition) (CONF:2219-2455).",
"min" : 0,
"max" : "*",
"type" : [
{
"code" : "Reference",
"targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10",
"path" : "Composition.section",
"sliceName" : "section_slice_pos10",
"label" : "History of Present Illness Section",
"short" : "History of Present Illness Section",
"definition" : "SHOULD contain zero or one [0..1] section (CONF:2219-1747) such that it",
"comments" : "History of Present Illness Section",
"min" : 0,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.title:section_slice_pos10",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos10",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1784).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.code:section_slice_pos10",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos10",
"label" : "History of Present Illness",
"short" : "History of Present Illness",
"definition" : "SHALL contain exactly one [1..1] code="10164-2" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1785).",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "CodeableConcept"
}
],
"patternCodeableConcept" : {
"coding" : [
{
"system" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "10164-2"
}
]
}
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.text:section_slice_pos10",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos10",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1786).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11",
"path" : "Composition.section",
"sliceName" : "section_slice_pos11",
"label" : "Immunizations Section",
"short" : "Immunizations Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1748) such that it",
"comments" : "Immunizations Section",
"min" : 0,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.title:section_slice_pos11",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos11",
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"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1819).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.entry:section_slice_pos21",
"path" : "Composition.section.entry",
"sliceName" : "section_slice_pos21",
"short" : "entry",
"definition" : "SHOULD contain zero or more [0..*] U.S. Core VitalSigns Profile (identifier: http://hl7.org/fhir/us/core/StructureDefinition/us-core-vitalsigns) (CONF:2219-2462).",
"min" : 0,
"max" : "*",
"type" : [
{
"code" : "Reference",
"targetProfile" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-vitalsigns"
}
]
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22",
"path" : "Composition.section",
"sliceName" : "section_slice_pos22",
"label" : "Instructions Section",
"short" : "Instructions Section",
"definition" : "MAY contain zero or one [0..1] section (CONF:2219-1759) such that it",
"comments" : "Instructions Section",
"min" : 0,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.title:section_slice_pos22",
"path" : "Composition.section.title",
"sliceName" : "section_slice_pos22",
"short" : "title",
"definition" : "SHALL contain exactly one [1..1] title (CONF:2219-1821).",
"min" : 1,
"max" : "1"
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.code:section_slice_pos22",
"path" : "Composition.section.code",
"sliceName" : "section_slice_pos22",
"label" : "Instructions",
"short" : "Instructions",
"definition" : "SHALL contain exactly one [1..1] code="69730-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1822).",
"min" : 1,
"max" : "1",
"type" : [
{
"code" : "CodeableConcept"
}
],
"patternCodeableConcept" : {
"coding" : [
{
"system" : "urn:oid:2.16.840.1.113883.6.1",
"code" : "69730-0"
}
]
}
},
{
"id" : "Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.text:section_slice_pos22",
"path" : "Composition.section.text",
"sliceName" : "section_slice_pos22",
"short" : "text",
"definition" : "SHALL contain exactly one [1..1] text (CONF:2219-1823).",
"min" : 1,
"max" : "1"
}
]
}
}
© HL7.org 2011+. FHIR STU3 Candidate (v1.8.0-10514) generated on Thu, Dec 8, 2016 06:39+1100. QA Page
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