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
<StructureDefinition xmlns="http://hl7.org/fhir"> <id value="CCDA-on-FHIR-History-and-Physical"/> <text> <status value="generated"/> <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> </text> <url value="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-History-and-Physical"/> <name value="C-CDA on FHIR History and Physical"/> <status value="draft"/> <publisher value="Lantana Consulting Group"/> <contact> <name value="Sarah Gaunt"/> <telecom> <system value="phone"/> <value value="+6 141-029-2506"/> <use value="work"/> </telecom> <telecom> <system value="email"/> <value value="sarah.gaunt@lantanagroup.com"/> <use value="work"/> </telecom> </contact> <date value="2016-12-08T06:39:19+11:00"/> <description value="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 value="rim"/> <uri value="http://hl7.org/v3"/> <name value="RIM Mapping"/> </mapping> <mapping> <identity value="cda"/> <uri value="http://hl7.org/v3/cda"/> <name value="CDA (R2)"/> </mapping> <mapping> <identity value="w5"/> <uri value="http://hl7.org/fhir/w5"/> <name value="W5 Mapping"/> </mapping> <kind value="resource"/> <abstract value="false"/> <contextType value="resource"/> <context value="Composition"/> <type value="Composition"/> <baseDefinition value="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-US-Realm-Header"/> <derivation value="constraint"/> <snapshot> <element id="Composition:c-cdaonfhirhistoryandphysical"> <path value="Composition"/> <short value="A set of resources composed into a single coherent clinical statement with clinical attestation"/> <definition value="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 value="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 value="0"/> <max value="*"/> <base> <path value="Composition"/> <min value="0"/> <max value="*"/> </base> <constraint> <key value="dom-2"/> <severity value="error"/> <human value="If the resource is contained in another resource, it SHALL NOT contain nested Resources"/> <expression value="contained.contained.empty()"/> <xpath value="not(parent::f:contained and f:contained)"/> <source value="DomainResource"/> </constraint> <constraint> <key value="dom-1"/> <severity value="error"/> <human value="If the resource is contained in another resource, it SHALL NOT contain any narrative"/> <expression value="contained.text.empty()"/> <xpath value="not(parent::f:contained and f:text)"/> <source value="DomainResource"/> </constraint> <constraint> <key value="dom-4"/> <severity value="error"/> <human value="If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated"/> <expression value="contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()"/> <xpath value="not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))"/> <source value="DomainResource"/> </constraint> <constraint> <key value="dom-3"/> <severity value="error"/> <human value="If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource"/> <expression value="contained.where(('#'+id in %resource.descendants().reference).not()).empty()"/> <xpath value="not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))"/> <source value="DomainResource"/> </constraint> <mapping> <identity value="rim"/> <map value="Entity. Role, or Act"/> </mapping> <mapping> <identity value="rim"/> <map value="Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]"/> </mapping> <mapping> <identity value="cda"/> <map value="ClinicalDocument"/> </mapping> <mapping> <identity value="w5"/> <map value="infrastructure.documents"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.id"> <path value="Composition.id"/> <short value="Logical id of this artifact"/> <definition value="The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes."/> <comments value="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 value="0"/> <max value="1"/> <base> <path value="Resource.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="id"/> </type> <isSummary value="true"/> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.meta"> <path value="Composition.meta"/> <short value="Metadata about the resource"/> <definition value="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 value="0"/> <max value="1"/> <base> <path value="Resource.meta"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Meta"/> </type> <isSummary value="true"/> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.implicitRules"> <path value="Composition.implicitRules"/> <short value="A set of rules under which this content was created"/> <definition value="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 value="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 value="0"/> <max value="1"/> <base> <path value="Resource.implicitRules"/> <min value="0"/> <max value="1"/> </base> <type> <code value="uri"/> </type> <isModifier value="true"/> <isSummary value="true"/> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.language"> <path value="Composition.language"/> <short value="language"/> <definition value="SHALL contain exactly one [1..1] language (CONF:2219-146)."/> <comments value="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 value="1"/> <max value="1"/> <base> <path value="Resource.language"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <binding> <extension url="http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet"> <valueReference> <reference value="http://hl7.org/fhir/ValueSet/all-languages"/> </valueReference> </extension> <strength value="extensible"/> <description value="A human language."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/languages"/> </valueSetReference> </binding> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.text"> <path value="Composition.text"/> <short value="Text summary of the resource, for human interpretation"/> <definition value="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 value="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 value="narrative"/> <alias value="html"/> <alias value="xhtml"/> <alias value="display"/> <min value="0"/> <max value="1"/> <base> <path value="DomainResource.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="dom-1"/> <mapping> <identity value="rim"/> <map value="Act.text?"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.contained"> <path value="Composition.contained"/> <short value="Contained, inline Resources"/> <definition value="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 value="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 value="inline resources"/> <alias value="anonymous resources"/> <alias value="contained resources"/> <min value="0"/> <max value="*"/> <base> <path value="DomainResource.contained"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Resource"/> </type> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.extension"> <path value="Composition.extension"/> <slicing> <discriminator value="Composition.url"/> <rules value="open"/> </slicing> <short value="Extension"/> <definition value="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 value="0"/> <max value="*"/> <base> <path value="DomainResource.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.extension:extension_slice_pos2"> <path value="Composition.extension"/> <sliceName value="extension_slice_pos2"/> <label value="dataEnterer"/> <short value="dataEnterer"/> <definition value="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 value="0"/> <max value="1"/> <base> <path value="DomainResource.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> <profile value="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer"/> </type> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.extension:extension_slice_pos3"> <path value="Composition.extension"/> <sliceName value="extension_slice_pos3"/> <label value="informant"/> <short value="informant"/> <definition value="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 value="0"/> <max value="*"/> <base> <path value="DomainResource.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> <profile value="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Informant"/> </type> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.extension:extension_slice_pos4"> <path value="Composition.extension"/> <sliceName value="extension_slice_pos4"/> <label value="informationRecipient"/> <short value="informationRecipient"/> <definition value="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 value="0"/> <max value="*"/> <base> <path value="DomainResource.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> <profile value="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient"/> </type> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.extension:extension_slice_pos5"> <path value="Composition.extension"/> <sliceName value="extension_slice_pos5"/> <label value="participant"/> <short value="participant"/> <definition value="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 value="0"/> <max value="*"/> <base> <path value="DomainResource.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> <profile value="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Participant"/> </type> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.extension:extension_slice_pos6"> <path value="Composition.extension"/> <sliceName value="extension_slice_pos6"/> <label value="performer"/> <short value="performer"/> <definition value="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 value="0"/> <max value="*"/> <base> <path value="DomainResource.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> <profile value="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Performer"/> </type> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.extension:extension_slice_pos7"> <path value="Composition.extension"/> <sliceName value="extension_slice_pos7"/> <label value="authorization"/> <short value="authorization"/> <definition value="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 value="0"/> <max value="*"/> <base> <path value="DomainResource.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> <profile value="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization"/> </type> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.modifierExtension"> <path value="Composition.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="DomainResource.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.identifier"> <path value="Composition.identifier"/> <short value="identifier"/> <definition value="SHALL contain exactly one [1..1] identifier (CONF:2219-147)."/> <comments value="See discussion in resource definition for how these relate."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.identifier"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Identifier"/> </type> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="Document.id / Document.setId"/> </mapping> <mapping> <identity value="cda"/> <map value=".setId"/> </mapping> <mapping> <identity value="w5"/> <map value="id"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.date"> <path value="Composition.date"/> <short value="date"/> <definition value="SHALL contain exactly one [1..1] date (CONF:2219-148)."/> <comments value="US Realm Datetime"/> <requirements value="dateTime is used for tracking, organizing versions and searching."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.date"/> <min value="1"/> <max value="1"/> </base> <type> <code value="dateTime"/> </type> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value=".effectiveTime[type="TS"]"/> </mapping> <mapping> <identity value="cda"/> <map value=".effectiveTime"/> </mapping> <mapping> <identity value="w5"/> <map value="when.done"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.type"> <path value="Composition.type"/> <label value="History and Physical"/> <short value="History and Physical"/> <definition value="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 value="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 value="Key metadata element describing the composition, used in searching/filtering."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.type"/> <min value="1"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <isSummary value="true"/> <binding> <strength value="required"/> <valueSetReference> <reference value="http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.1.11.20.22"/> <display value="HPDocumentType"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.class"> <path value="Composition.class"/> <short value="Categorization of Composition"/> <definition value="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 value="This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD))."/> <requirements value="Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.class"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <isSummary value="true"/> <binding> <strength value="example"/> <description value="High-level kind of a clinical document at a macro level."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-classcodes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.title"> <path value="Composition.title"/> <label value="Document Title"/> <short value="Document Title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-150)."/> <comments value="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 value="1"/> <max value="1"/> <base> <path value="Composition.title"/> <min value="1"/> <max value="1"/> </base> <type> <code value="string"/> </type> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.status"> <path value="Composition.status"/> <short value="status"/> <definition value="SHALL contain exactly one [1..1] status (CONF:2219-1048)."/> <comments value="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 value="Need to be able to mark interim, amended, or withdrawn compositions or documents."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.status"/> <min value="1"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The workflow/clinical status of the composition."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/composition-status"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="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""/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="status"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.confidentiality"> <path value="Composition.confidentiality"/> <short value="confidentiality"/> <definition value="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 value="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 value="1"/> <max value="1"/> <base> <path value="Composition.confidentiality"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/v3-ConfidentialityClassification"/> <display value="v3-ConfidentialityClassification"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".confidentialityCode"/> </mapping> <mapping> <identity value="cda"/> <map value=".confidentialityCode"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.subject"> <path value="Composition.subject"/> <label value="recordTarget"/> <short value="recordTarget"/> <definition value="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 value="U.S. DAF Patient"/> <requirements value="Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.subject"/> <min value="1"/> <max value="1"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient"/> </type> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value=".participation[typeCode="SBJ"].role[typeCode="PAT"]"/> </mapping> <mapping> <identity value="cda"/> <map value=".recordTarget"/> </mapping> <mapping> <identity value="w5"/> <map value="who.focus"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.author"> <path value="Composition.author"/> <label value="author"/> <short value="author"/> <definition value="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 value="U.S. DAF Practitioner"/> <requirements value="Identifies who is responsible for the content."/> <min value="1"/> <max value="*"/> <base> <path value="Composition.author"/> <min value="1"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-pract"/> </type> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Device"/> </type> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value=".participation[typeCode="AUT"].role[classCode="ASSIGNED"]"/> </mapping> <mapping> <identity value="cda"/> <map value=".author.assignedAuthor"/> </mapping> <mapping> <identity value="w5"/> <map value="who.author"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester"> <path value="Composition.attester"/> <slicing> <discriminator value="Composition.attester.mode"/> <rules value="open"/> </slicing> <short value="Attests to accuracy of composition"/> <definition value="MAY contain zero or more [0..*] attester (CONF:2219-2083) such that it"/> <comments value="Only list each attester once."/> <requirements value="Identifies responsibility for the accuracy of the composition content."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.attester"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value=".participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]"/> </mapping> <mapping> <identity value="cda"/> <map value=".authenticator/.legalAuthenticator"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16"> <path value="Composition.attester"/> <sliceName value="attester_slice_pos16"/> <short value="attester"/> <definition value="SHOULD contain zero or one [0..1] attester (CONF:2219-2082) such that it"/> <comments value="Only list each attester once."/> <requirements value="Identifies responsibility for the accuracy of the composition content."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.attester"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value=".participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]"/> </mapping> <mapping> <identity value="cda"/> <map value=".authenticator/.legalAuthenticator"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16.id"> <path value="Composition.attester.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16.extension"> <path value="Composition.attester.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16.modifierExtension"> <path value="Composition.attester.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16.mode:attester_slice_pos16"> <path value="Composition.attester.mode"/> <sliceName value="attester_slice_pos16"/> <short value="mode"/> <definition value="SHALL contain exactly one [1..1] mode="legal" (CodeSystem: FHIR CompositionAttestationMode http://hl7.org/fhir/composition-attestation-mode) (CONF:2219-2084)."/> <comments value="Use more than one code where a single attester has more than one mode (professional and legal are often paired)."/> <requirements value="Indicates the level of authority of the attestation."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.attester.mode"/> <min value="1"/> <max value="*"/> </base> <type> <code value="code"/> </type> <patternString value="legal"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The way in which a person authenticated a composition."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/composition-attestation-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="unique(./modeCode)"/> </mapping> <mapping> <identity value="cda"/> <map value="implied by .authenticator/.legalAuthenticator"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16.time"> <path value="Composition.attester.time"/> <short value="When composition attested"/> <definition value="When composition was attested by the party."/> <requirements value="Identifies when the information in the composition was deemed accurate. (Things may have changed since then.)."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.attester.time"/> <min value="0"/> <max value="1"/> </base> <type> <code value="dateTime"/> </type> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="./time[type="TS" and isNormalDatatype()]"/> </mapping> <mapping> <identity value="cda"/> <map value=".authenticator.time"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos16.party:attester_slice_pos16"> <path value="Composition.attester.party"/> <sliceName value="attester_slice_pos16"/> <short value="party"/> <definition value="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 value="Identifies who has taken on the responsibility for accuracy of the composition content."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.attester.party"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-pract"/> </type> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="./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()]"/> </mapping> <mapping> <identity value="cda"/> <map value=".authenticator.assignedEnttty"/> </mapping> <mapping> <identity value="w5"/> <map value="who.witness"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17"> <path value="Composition.attester"/> <sliceName value="attester_slice_pos17"/> <short value="attester"/> <definition value="MAY contain zero or more [0..*] attester (CONF:2219-2083) such that it"/> <comments value="Only list each attester once."/> <requirements value="Identifies responsibility for the accuracy of the composition content."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.attester"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value=".participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]"/> </mapping> <mapping> <identity value="cda"/> <map value=".authenticator/.legalAuthenticator"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17.id"> <path value="Composition.attester.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17.extension"> <path value="Composition.attester.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17.modifierExtension"> <path value="Composition.attester.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17.mode:attester_slice_pos17"> <path value="Composition.attester.mode"/> <sliceName value="attester_slice_pos17"/> <short value="mode"/> <definition value="SHALL contain at least one [1..*] mode (CONF:2219-2086)."/> <comments value="Use more than one code where a single attester has more than one mode (professional and legal are often paired)."/> <requirements value="Indicates the level of authority of the attestation."/> <min value="1"/> <max value="*"/> <base> <path value="Composition.attester.mode"/> <min value="1"/> <max value="*"/> </base> <type> <code value="code"/> </type> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The way in which a person authenticated a composition."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/composition-attestation-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="unique(./modeCode)"/> </mapping> <mapping> <identity value="cda"/> <map value="implied by .authenticator/.legalAuthenticator"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17.time"> <path value="Composition.attester.time"/> <short value="When composition attested"/> <definition value="When composition was attested by the party."/> <requirements value="Identifies when the information in the composition was deemed accurate. (Things may have changed since then.)."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.attester.time"/> <min value="0"/> <max value="1"/> </base> <type> <code value="dateTime"/> </type> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="./time[type="TS" and isNormalDatatype()]"/> </mapping> <mapping> <identity value="cda"/> <map value=".authenticator.time"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.attester:attester_slice_pos17.party:attester_slice_pos17"> <path value="Composition.attester.party"/> <sliceName value="attester_slice_pos17"/> <short value="party"/> <definition value="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 value="Identifies who has taken on the responsibility for accuracy of the composition content."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.attester.party"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-pract"/> </type> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="./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()]"/> </mapping> <mapping> <identity value="cda"/> <map value=".authenticator.assignedEnttty"/> </mapping> <mapping> <identity value="w5"/> <map value="who.witness"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.custodian"> <path value="Composition.custodian"/> <label value="custodian"/> <short value="custodian"/> <definition value="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 value="U.S. DAF Organization"/> <requirements value="Identifies where to go to find the current version, where to report issues, etc."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.custodian"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization"/> </type> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value=".participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]"/> </mapping> <mapping> <identity value="cda"/> <map value=".custodian.assignedCustodian"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.event"> <path value="Composition.event"/> <short value="The clinical service(s) being documented"/> <definition value="The clinical service, such as a colonoscopy or an appendectomy, being documented."/> <comments value="The event needs to be consistent with the type element, though can provide further information if desired."/> <requirements value="Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.event"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']"/> </mapping> <mapping> <identity value="cda"/> <map value=".documentationOf.serviceEvent"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.event.id"> <path value="Composition.event.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.event.extension"> <path value="Composition.event.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.event.modifierExtension"> <path value="Composition.event.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.event.code"> <path value="Composition.event.code"/> <short value="Code(s) that apply to the event being documented"/> <definition value="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 value="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 value="0"/> <max value="*"/> <base> <path value="Composition.event.code"/> <min value="0"/> <max value="*"/> </base> <type> <code value="CodeableConcept"/> </type> <isSummary value="true"/> <binding> <strength value="example"/> <description value="This list of codes represents the main clinical acts being documented."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/v3-ActCode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.event.period"> <path value="Composition.event.period"/> <short value="The period covered by the documentation"/> <definition value="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 value="0"/> <max value="1"/> <base> <path value="Composition.event.period"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Period"/> </type> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value=".effectiveTime"/> </mapping> <mapping> <identity value="cda"/> <map value=".effectiveTime"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.event.detail"> <path value="Composition.event.detail"/> <short value="The event(s) being documented"/> <definition value="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 value="0"/> <max value="*"/> <base> <path value="Composition.event.detail"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode="SUBJ"].target"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.encounter"> <path value="Composition.encounter"/> <short value="Context of the Composition"/> <definition value="Describes the clinical encounter or type of care this documentation is associated with."/> <requirements value="Provides context for the composition and supports searching."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.encounter"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Encounter"/> </type> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])"/> </mapping> <mapping> <identity value="cda"/> <map value=".componentOf.encompassingEncounter"/> </mapping> <mapping> <identity value="w5"/> <map value="context"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <slicing> <discriminator value="Composition.section.code"/> <rules value="open"/> </slicing> <short value="Composition is broken into sections"/> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1759) such that it"/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos2"/> <label value="Allergies and Intolerances Section"/> <short value="Allergies and Intolerances Section"/> <definition value="SHALL contain exactly one [1..1] section (CONF:2219-1739) such that it"/> <comments value="Allergies and Intolerances Section"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.title:section_slice_pos2"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos2"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1760)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.code:section_slice_pos2"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos2"/> <label value="Allergies, adverse reactions, alerts"/> <short value="Allergies, adverse reactions, alerts"/> <definition value="SHALL contain exactly one [1..1] code="48765-2" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1761)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="48765-2"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.text:section_slice_pos2"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos2"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1762)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.entry:section_slice_pos2"> <path value="Composition.section.entry"/> <sliceName value="section_slice_pos2"/> <short value="entry"/> <definition value="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 value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos3"/> <label value="Assessment and Plan Section"/> <short value="Assessment and Plan Section"/> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1740) such that it"/> <comments value="Assessment and Plan Section"/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.title:section_slice_pos3"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos3"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1763)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.code:section_slice_pos3"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos3"/> <label value="Assessment and Plan"/> <short value="Assessment and Plan"/> <definition value="SHALL contain exactly one [1..1] code="51847-2" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1764)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="51847-2"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.text:section_slice_pos3"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos3"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1765)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.entry"> <path value="Composition.section.entry"/> <short value="A reference to data that supports this section"/> <definition value="A reference to the actual resource from which the narrative in the section is derived."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos4"/> <label value="Assessment Section"/> <short value="Assessment Section"/> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1741) such that it"/> <comments value="Assessment Section"/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.title:section_slice_pos4"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos4"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1766)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.code:section_slice_pos4"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos4"/> <label value="Assessments"/> <short value="Assessments"/> <definition value="SHALL contain exactly one [1..1] code="51848-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1767)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="51848-0"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.text:section_slice_pos4"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos4"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1768)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.entry"> <path value="Composition.section.entry"/> <short value="A reference to data that supports this section"/> <definition value="A reference to the actual resource from which the narrative in the section is derived."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos5"/> <label value="Chief Complaint and Reason for Visit Section"/> <short value="Chief Complaint and Reason for Visit Section"/> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1742) such that it"/> <comments value="Chief Complaint and Reason for Visit Section"/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.title:section_slice_pos5"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos5"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1769)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.code:section_slice_pos5"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos5"/> <label value="Chief Complaint and Reason for Visit"/> <short value="Chief Complaint and Reason for Visit"/> <definition value="SHALL contain exactly one [1..1] code="46239-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1770)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="46239-0"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.text:section_slice_pos5"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos5"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1771)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.entry"> <path value="Composition.section.entry"/> <short value="A reference to data that supports this section"/> <definition value="A reference to the actual resource from which the narrative in the section is derived."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos5"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos6"/> <label value="Chief Complaint Section"/> <short value="Chief Complaint Section"/> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1743) such that it"/> <comments value="Chief Complaint Section"/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.title:section_slice_pos6"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos6"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1772)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.code:section_slice_pos6"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos6"/> <label value="Chief Complaint"/> <short value="Chief Complaint"/> <definition value="SHALL contain exactly one [1..1] code="10154-3" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1773)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="10154-3"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.text:section_slice_pos6"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos6"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1774)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.entry"> <path value="Composition.section.entry"/> <short value="A reference to data that supports this section"/> <definition value="A reference to the actual resource from which the narrative in the section is derived."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos6"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos7"/> <label value="Family History Section"/> <short value="Family History Section"/> <definition value="SHALL contain exactly one [1..1] section (CONF:2219-1744) such that it"/> <comments value="Family History Section"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.title:section_slice_pos7"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos7"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1775)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.code:section_slice_pos7"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos7"/> <label value="Family History"/> <short value="Family History"/> <definition value="SHALL contain exactly one [1..1] code="10157-6" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1776)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="10157-6"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.text:section_slice_pos7"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos7"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1777)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.entry:section_slice_pos7"> <path value="Composition.section.entry"/> <sliceName value="section_slice_pos7"/> <short value="entry"/> <definition value="MAY contain zero or more [0..*] FamilyMemberHistory (identifier: http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory) (CONF:2219-2454)."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value="Entity. Role, or Act"/> </mapping> <mapping> <identity value="v2"/> <map value="Not in scope for v2"/> </mapping> <mapping> <identity value="rim"/> <map value="Observation[classCode=OBS, moodCode=EVN]"/> </mapping> <mapping> <identity value="w5"/> <map value="clinical.general"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos7"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos8"/> <label value="General Status Section"/> <short value="General Status Section"/> <definition value="SHALL contain exactly one [1..1] section (CONF:2219-1745) such that it"/> <comments value="General Status Section"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.title:section_slice_pos8"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos8"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1778)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.code:section_slice_pos8"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos8"/> <label value="General Status"/> <short value="General Status"/> <definition value="SHALL contain exactly one [1..1] code="10210-3" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1779)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="10210-3"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.text:section_slice_pos8"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos8"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1780)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.entry"> <path value="Composition.section.entry"/> <short value="A reference to data that supports this section"/> <definition value="A reference to the actual resource from which the narrative in the section is derived."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos8"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos9"/> <label value="History of Past Illness Section"/> <short value="History of Past Illness Section"/> <definition value="SHALL contain exactly one [1..1] section (CONF:2219-1746) such that it"/> <comments value="History of Past Illness Section"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.title:section_slice_pos9"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos9"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1781)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.code:section_slice_pos9"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos9"/> <label value="History of Past Illness"/> <short value="History of Past Illness"/> <definition value="SHALL contain exactly one [1..1] code="11348-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1782)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="11348-0"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.text:section_slice_pos9"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos9"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1783)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.entry:section_slice_pos9"> <path value="Composition.section.entry"/> <sliceName value="section_slice_pos9"/> <short value="entry"/> <definition value="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 value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos9"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos10"/> <label value="History of Present Illness Section"/> <short value="History of Present Illness Section"/> <definition value="SHOULD contain zero or one [0..1] section (CONF:2219-1747) such that it"/> <comments value="History of Present Illness Section"/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.title:section_slice_pos10"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos10"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1784)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.code:section_slice_pos10"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos10"/> <label value="History of Present Illness"/> <short value="History of Present Illness"/> <definition value="SHALL contain exactly one [1..1] code="10164-2" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1785)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="10164-2"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.text:section_slice_pos10"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos10"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1786)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.entry"> <path value="Composition.section.entry"/> <short value="A reference to data that supports this section"/> <definition value="A reference to the actual resource from which the narrative in the section is derived."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos10"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos11"/> <label value="Immunizations Section"/> <short value="Immunizations Section"/> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1748) such that it"/> <comments value="Immunizations Section"/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.title:section_slice_pos11"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos11"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1787)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.code:section_slice_pos11"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos11"/> <label value="Immunizations"/> <short value="Immunizations"/> <definition value="SHALL contain exactly one [1..1] code="11369-6" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1788)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="11369-6"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.text:section_slice_pos11"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos11"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1789)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.entry:section_slice_pos11"> <path value="Composition.section.entry"/> <sliceName value="section_slice_pos11"/> <short value="entry"/> <definition value="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 value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos11"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos12"/> <label value="Medications Section"/> <short value="Medications Section"/> <definition value="SHALL contain exactly one [1..1] section (CONF:2219-1749) such that it"/> <comments value="Medications Section"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.title:section_slice_pos12"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos12"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1790)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.code:section_slice_pos12"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos12"/> <label value="History of medication use"/> <short value="History of medication use"/> <definition value="SHALL contain exactly one [1..1] code="10160-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1791)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="10160-0"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.text:section_slice_pos12"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos12"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1792)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.entry:section_slice_pos12"> <path value="Composition.section.entry"/> <sliceName value="section_slice_pos12"/> <short value="entry"/> <definition value="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 value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationstatement"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos12"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos13"/> <label value="Physical Exam Section"/> <short value="Physical Exam Section"/> <definition value="SHALL contain exactly one [1..1] section (CONF:2219-1750) such that it"/> <comments value="Physical Exam Section"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.title:section_slice_pos13"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos13"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1793)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.code:section_slice_pos13"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos13"/> <label value="Physical Findings"/> <short value="Physical Findings"/> <definition value="SHALL contain exactly one [1..1] code="29545-1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1794)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="29545-1"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.text:section_slice_pos13"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos13"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1795)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.entry"> <path value="Composition.section.entry"/> <short value="A reference to data that supports this section"/> <definition value="A reference to the actual resource from which the narrative in the section is derived."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos13"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos14"/> <label value="Plan of Treatment Section"/> <short value="Plan of Treatment Section"/> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1751) such that it"/> <comments value="Plan of Treatment Section"/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.title:section_slice_pos14"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos14"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1796)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.code:section_slice_pos14"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos14"/> <label value="Plan of Treatment"/> <short value="Plan of Treatment"/> <definition value="SHALL contain exactly one [1..1] code="18776-5" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1797)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="18776-5"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.text:section_slice_pos14"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos14"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1798)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.entry"> <path value="Composition.section.entry"/> <short value="A reference to data that supports this section"/> <definition value="A reference to the actual resource from which the narrative in the section is derived."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos14"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos15"/> <label value="Problem Section"/> <short value="Problem Section"/> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1752) such that it"/> <comments value="Problem Section"/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.title:section_slice_pos15"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos15"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1799)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.code:section_slice_pos15"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos15"/> <label value="Problem List"/> <short value="Problem List"/> <definition value="SHALL contain exactly one [1..1] code="11450-4" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1800)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="11450-4"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.text:section_slice_pos15"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos15"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1801)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.entry:section_slice_pos15"> <path value="Composition.section.entry"/> <sliceName value="section_slice_pos15"/> <short value="entry"/> <definition value="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 value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos15"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos16"/> <label value="Procedures Section"/> <short value="Procedures Section"/> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1753) such that it"/> <comments value="Procedures Section"/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.title:section_slice_pos16"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos16"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1802)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.code:section_slice_pos16"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos16"/> <label value="History of Procedures"/> <short value="History of Procedures"/> <definition value="SHALL contain exactly one [1..1] code="47519-4" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1803)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="47519-4"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.text:section_slice_pos16"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos16"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1804)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.entry:section_slice_pos16"> <path value="Composition.section.entry"/> <sliceName value="section_slice_pos16"/> <short value="entry"/> <definition value="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 value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos16"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos17"/> <label value="Reason for Visit Section"/> <short value="Reason for Visit Section"/> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1754) such that it"/> <comments value="Reason for Visit Section"/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.title:section_slice_pos17"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos17"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1805)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.code:section_slice_pos17"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos17"/> <label value="Reason for Visit"/> <short value="Reason for Visit"/> <definition value="SHALL contain exactly one [1..1] code="29299-5" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1806)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="29299-5"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.text:section_slice_pos17"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos17"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1807)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.entry"> <path value="Composition.section.entry"/> <short value="A reference to data that supports this section"/> <definition value="A reference to the actual resource from which the narrative in the section is derived."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos17"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos18"/> <label value="Results Section"/> <short value="Results Section"/> <definition value="SHALL contain exactly one [1..1] section (CONF:2219-1755) such that it"/> <comments value="Results Section"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.title:section_slice_pos18"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos18"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1808)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.code:section_slice_pos18"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos18"/> <label value="Relevant diagnostic tests and/or laboratory data"/> <short value="Relevant diagnostic tests and/or laboratory data"/> <definition value="SHALL contain exactly one [1..1] code="30954-2" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1809)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="30954-2"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.text:section_slice_pos18"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos18"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1810)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.entry"> <path value="Composition.section.entry"/> <short value="A reference to data that supports this section"/> <definition value="A reference to the actual resource from which the narrative in the section is derived."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos18"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos19"/> <label value="Review of Systems Section"/> <short value="Review of Systems Section"/> <definition value="SHALL contain exactly one [1..1] section (CONF:2219-1756) such that it"/> <comments value="Review of Systems Section"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.title:section_slice_pos19"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos19"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1811)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.code:section_slice_pos19"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos19"/> <label value="Review of Systems"/> <short value="Review of Systems"/> <definition value="SHALL contain exactly one [1..1] code="10187-3" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1812)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="10187-3"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.text:section_slice_pos19"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos19"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1813)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.entry"> <path value="Composition.section.entry"/> <short value="A reference to data that supports this section"/> <definition value="A reference to the actual resource from which the narrative in the section is derived."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos19"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos20"/> <label value="Social History Section"/> <short value="Social History Section"/> <definition value="SHALL contain exactly one [1..1] section (CONF:2219-1757) such that it"/> <comments value="Social History Section"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.title:section_slice_pos20"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos20"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1814)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.code:section_slice_pos20"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos20"/> <label value="Social History"/> <short value="Social History"/> <definition value="SHALL contain exactly one [1..1] code="29762-2" (CONF:2219-1815)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <code value="29762-2"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.text:section_slice_pos20"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos20"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1816)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.entry:section_slice_pos20"> <path value="Composition.section.entry"/> <sliceName value="section_slice_pos20"/> <short value="entry"/> <definition value="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 value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos20"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos21"/> <label value="Vital Signs Section"/> <short value="Vital Signs Section"/> <definition value="SHALL contain exactly one [1..1] section (CONF:2219-1758) such that it"/> <comments value="Vital Signs Section"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.title:section_slice_pos21"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos21"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1817)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.code:section_slice_pos21"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos21"/> <label value="Vital Signs"/> <short value="Vital Signs"/> <definition value="SHALL contain exactly one [1..1] code="8716-3" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1818)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="8716-3"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.text:section_slice_pos21"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos21"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1819)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.entry:section_slice_pos21"> <path value="Composition.section.entry"/> <sliceName value="section_slice_pos21"/> <short value="entry"/> <definition value="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 value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-vitalsigns"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos21"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <sliceName value="section_slice_pos22"/> <label value="Instructions Section"/> <short value="Instructions Section"/> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1759) such that it"/> <comments value="Instructions Section"/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="ele-1"/> <severity value="error"/> <human value="All FHIR elements must have a @value or children"/> <expression value="children().count() > id.count()"/> <xpath value="@value|f:*|h:div"/> <source value="Element"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text.exists() or entry.exists() or section.exists()"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> <source value="Composition:c-cdaonfhirusrealmheader.section"/> </constraint> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.id"> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.extension"> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.modifierExtension"> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.title:section_slice_pos22"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos22"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1821)."/> <comments value="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 value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.code:section_slice_pos22"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos22"/> <label value="Instructions"/> <short value="Instructions"/> <definition value="SHALL contain exactly one [1..1] code="69730-0" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1822)."/> <comments value="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 value="Provides computable standardized labels to topics within the document."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="69730-0"/> </coding> </patternCodeableConcept> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.text:section_slice_pos22"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos22"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1823)."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.mode"> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="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 value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.orderedBy"> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="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 value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.entry"> <path value="Composition.section.entry"/> <short value="A reference to data that supports this section"/> <definition value="A reference to the actual resource from which the narrative in the section is derived."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <condition value="cmp-2"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.emptyReason"> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="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 value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22.section"> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos22"/> <condition value="cmp-1"/> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> </element> </snapshot> <differential> <element id="Composition:c-cdaonfhirhistoryandphysical"> <path value="Composition"/> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.type"> <path value="Composition.type"/> <label value="History and Physical"/> <short value="History and Physical"/> <definition value="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 value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="required"/> <valueSetReference> <reference value="http://hl7.org/fhir/ccda/ValueSet/2.16.840.1.113883.1.11.20.22"/> <display value="HPDocumentType"/> </valueSetReference> </binding> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section"> <path value="Composition.section"/> <slicing> <discriminator value="Composition.section.code"/> <rules value="open"/> </slicing> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1759) such that it"/> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2"> <path value="Composition.section"/> <sliceName value="section_slice_pos2"/> <label value="Allergies and Intolerances Section"/> <short value="Allergies and Intolerances Section"/> <definition value="SHALL contain exactly one [1..1] section (CONF:2219-1739) such that it"/> <comments value="Allergies and Intolerances Section"/> <min value="1"/> <max value="1"/> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.title:section_slice_pos2"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos2"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1760)."/> <min value="1"/> <max value="1"/> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.code:section_slice_pos2"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos2"/> <label value="Allergies, adverse reactions, alerts"/> <short value="Allergies, adverse reactions, alerts"/> <definition value="SHALL contain exactly one [1..1] code="48765-2" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1761)."/> <min value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="48765-2"/> </coding> </patternCodeableConcept> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.text:section_slice_pos2"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos2"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1762)."/> <min value="1"/> <max value="1"/> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos2.entry:section_slice_pos2"> <path value="Composition.section.entry"/> <sliceName value="section_slice_pos2"/> <short value="entry"/> <definition value="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 value="0"/> <max value="*"/> <type> <code value="Reference"/> <targetProfile value="http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance"/> </type> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3"> <path value="Composition.section"/> <sliceName value="section_slice_pos3"/> <label value="Assessment and Plan Section"/> <short value="Assessment and Plan Section"/> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1740) such that it"/> <comments value="Assessment and Plan Section"/> <min value="0"/> <max value="1"/> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.title:section_slice_pos3"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos3"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1763)."/> <min value="1"/> <max value="1"/> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.code:section_slice_pos3"> <path value="Composition.section.code"/> <sliceName value="section_slice_pos3"/> <label value="Assessment and Plan"/> <short value="Assessment and Plan"/> <definition value="SHALL contain exactly one [1..1] code="51847-2" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2219-1764)."/> <min value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <patternCodeableConcept> <coding> <system value="urn:oid:2.16.840.1.113883.6.1"/> <code value="51847-2"/> </coding> </patternCodeableConcept> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos3.text:section_slice_pos3"> <path value="Composition.section.text"/> <sliceName value="section_slice_pos3"/> <short value="text"/> <definition value="SHALL contain exactly one [1..1] text (CONF:2219-1765)."/> <min value="1"/> <max value="1"/> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4"> <path value="Composition.section"/> <sliceName value="section_slice_pos4"/> <label value="Assessment Section"/> <short value="Assessment Section"/> <definition value="MAY contain zero or one [0..1] section (CONF:2219-1741) such that it"/> <comments value="Assessment Section"/> <min value="0"/> <max value="1"/> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.title:section_slice_pos4"> <path value="Composition.section.title"/> <sliceName value="section_slice_pos4"/> <short value="title"/> <definition value="SHALL contain exactly one [1..1] title (CONF:2219-1766)."/> <min value="1"/> <max value="1"/> </element> <element id="Composition:c-cdaonfhirhistoryandphysical.section:section_slice_pos4.code:section_slice_pos4"> 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