NHSN Reporting: Inpatient Medication Administration
1.0.0 - STU 1
NHSN Reporting: Inpatient Medication Administration
1.0.0 - STU 1
This page is part of the NHSN Reporting: Inpatient Medication Administration (v1.0.0: STU 1 on FHIR R4) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
| Defining URL: | http://hl7.org/fhir/us/nhsn-med-admin/StructureDefinition/Composition-inpatient-med-admin |
| Version: | 1.0.0 |
| Name: | CompositionInpatientMedAdmin |
| Title: | Composition - Inpatient Medication Administration |
| Status: | Active as of 2021-10-12T13:08:53+00:00 |
| Definition: | This profile supports the electronic submission of line-level medication administration data to the National Healthcare Safety Network (NHSN). |
| Publisher: | HL7 International - Pharmacy Work Group |
| Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
http://hl7.org/fhir/us/nhsn-med-admin/StructureDefinition/Composition-inpatient-med-admin
This Composition contains all conditions, results, and medications relevant to and generated during an encounter for patients diagnosed with COVID-19. It should contain information about all medications administered to these hospitalized patients (inpatients) and all medication administration events should be reported irrespective of whether or not medication administration was linked to an adverse event.
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
Summary
Mandatory: 18 elements (4 nested mandatory elements)
Must-Support: 28 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  identifier | S | 1..1 | Identifier | Version-independent identifier for the Composition |
 type | S | 1..1 | CodeableConcept | Medication administration.extended Required Pattern: At least the following |
   coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
 system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 87231-7 | |
 subject | S | 1..1 | Reference(US Core Patient Profile) | Who and/or what the composition is about |
| encounter | S | 1..1 | Reference(US Core Encounter Profile) | Context of the Composition |
| date | S | 1..1 | dateTime | Composition editing time |
 Slices for section | S | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code |
  section:medicationSection | S | 1..1 | BackboneElement | If both MedicationAdministration and MedicationRequest data are available, populate both resources. |
  title | S | 1..1 | string | Label for section (e.g. for ToC) |
 code | S | 1..1 | CodeableConcept | Medication use Required Pattern: At least the following |
 coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| text | S | 0..1 | Narrative | Text summary of the section, for human interpretation |
 Slices for entry | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
 entry:medicationAdministration | 0..* | Reference(Medication Administration - Inpatient Med Admin) | A reference to data that supports this section | |
 entry:USCoreMedicationRequest | 0..* | Reference(US Core MedicationRequest Profile) | A reference to data that supports this section | |
| section:problemSection | S | 1..1 | BackboneElement | When the condition matches one of the codes in the Confirmed COVID-19 value set use the Observation - Laboratory SARS COVID-19 profile, when the condition matches one of the codes in the Suspected COVID-19 value set use the Observation - Laboratory SARS COVID-19 profile. For all other relevant conditions use the US Core Condition profile. |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Problem list Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| text | S | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | S | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:Condition | S | 1..* | Reference(Condition - Lab Confirmed COVID-19 | Condition - Suspected COVID-19 | US Core Condition Profile) | A reference to data that supports this section |
| section:resultSection | S | 1..1 | BackboneElement | When the lab test matches one of the codes in the SARS COVID-19 value set populate the Observation - Laboratory SARS COVID-19 profile. For all other relevant lab results, use the US Core Lab Result profile. |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Relevant diagnostic tests &or laboratory data Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| text | S | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | S | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:ObservationLab | S | 1..* | Reference(US Core Laboratory Result Observation Profile | Observation Laboratory SARS COVID-19) | A reference to data that supports this section |
 section:adverseEventSection | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Adverse Event Section Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 85893-6 | |
| text | S | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | S | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:AdverseEvent | S | 1..* | Reference(AdverseEvent) | A reference to data that supports this section |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
 id | Σ | 0..1 | string | Logical id of this artifact |
 meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | 0..* | Extension | Additional content defined by implementations | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SΣ | 1..1 | Identifier | Version-independent identifier for the Composition |
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | SΣ | 1..1 | CodeableConcept | Medication administration.extended Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 87231-7 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the composition is about |
| encounter | SΣ | 1..1 | Reference(US Core Encounter Profile) | Context of the Composition |
| date | SΣ | 1..1 | dateTime | Composition editing time |
| author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
| title | Σ | 1..1 | string | Human Readable name/title |
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. |
| attester | 0..* | BackboneElement | Attests to accuracy of composition | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
| time | 0..1 | dateTime | When the composition was attested | |
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |
 target[x] | 1..1 | Target of the relationship | ||
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition) | |||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
| period | Σ | 0..1 | Period | The period covered by the documentation |
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
| Slices for section | SI | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code |
| section:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:medicationSection | SI | 1..1 | BackboneElement | If both MedicationAdministration and MedicationRequest data are available, populate both resources. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | SI | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| Slices for entry | I | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:medicationAdministration | I | 0..* | Reference(Medication Administration - Inpatient Med Admin) | A reference to data that supports this section |
| entry:USCoreMedicationRequest | I | 0..* | Reference(US Core MedicationRequest Profile) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
 section | I | 0..* | See section (Composition) | Nested Section |
| section:problemSection | SI | 1..1 | BackboneElement | When the condition matches one of the codes in the Confirmed COVID-19 value set use the Observation - Laboratory SARS COVID-19 profile, when the condition matches one of the codes in the Suspected COVID-19 value set use the Observation - Laboratory SARS COVID-19 profile. For all other relevant conditions use the US Core Condition profile. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Problem list Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | SI | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| Slices for entry | SI | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:Condition | SI | 1..* | Reference(Condition - Lab Confirmed COVID-19 | Condition - Suspected COVID-19 | US Core Condition Profile) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:resultSection | SI | 1..1 | BackboneElement | When the lab test matches one of the codes in the SARS COVID-19 value set populate the Observation - Laboratory SARS COVID-19 profile. For all other relevant lab results, use the US Core Lab Result profile. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Relevant diagnostic tests &or laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | SI | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| Slices for entry | SI | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:ObservationLab | SI | 1..* | Reference(US Core Laboratory Result Observation Profile | Observation Laboratory SARS COVID-19) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:adverseEventSection | SI | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Adverse Event Section Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 85893-6 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | SI | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| Slices for entry | SI | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:AdverseEvent | SI | 1..* | Reference(AdverseEvent) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| identifier | Σ | 1..1 | Identifier | Version-independent identifier for the Composition |
| type | Σ | 1..1 | CodeableConcept | Medication administration.extended Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 87231-7 | |
| subject | Σ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the composition is about |
| encounter | Σ | 1..1 | Reference(US Core Encounter Profile) | Context of the Composition |
| date | Σ | 1..1 | dateTime | Composition editing time |
| Slices for section | I | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code |
| section:medicationSection | I | 1..1 | BackboneElement | If both MedicationAdministration and MedicationRequest data are available, populate both resources. |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConcept | Medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| section:problemSection | I | 1..1 | BackboneElement | When the condition matches one of the codes in the Confirmed COVID-19 value set use the Observation - Laboratory SARS COVID-19 profile, when the condition matches one of the codes in the Suspected COVID-19 value set use the Observation - Laboratory SARS COVID-19 profile. For all other relevant conditions use the US Core Condition profile. |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConcept | Problem list Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | I | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:Condition | I | 1..* | Reference(Condition - Lab Confirmed COVID-19 | Condition - Suspected COVID-19 | US Core Condition Profile) | A reference to data that supports this section |
| section:resultSection | I | 1..1 | BackboneElement | When the lab test matches one of the codes in the SARS COVID-19 value set populate the Observation - Laboratory SARS COVID-19 profile. For all other relevant lab results, use the US Core Lab Result profile. |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConcept | Relevant diagnostic tests &or laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | I | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:ObservationLab | I | 1..* | Reference(US Core Laboratory Result Observation Profile | Observation Laboratory SARS COVID-19) | A reference to data that supports this section |
| section:adverseEventSection | I | 0..1 | BackboneElement | Composition is broken into sections |
| title | 1..1 | string | Label for section (e.g. for ToC) | |
| code | 1..1 | CodeableConcept | Adverse Event Section Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 85893-6 | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | I | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:AdverseEvent | I | 1..* | Reference(AdverseEvent) | A reference to data that supports this section |
| Documentation for this format | ||||
This structure is derived from Composition
Summary
Mandatory: 18 elements (4 nested mandatory elements)
Must-Support: 28 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| identifier | S | 1..1 | Identifier | Version-independent identifier for the Composition |
| type | S | 1..1 | CodeableConcept | Medication administration.extended Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 87231-7 | |
| subject | S | 1..1 | Reference(US Core Patient Profile) | Who and/or what the composition is about |
| encounter | S | 1..1 | Reference(US Core Encounter Profile) | Context of the Composition |
| date | S | 1..1 | dateTime | Composition editing time |
| Slices for section | S | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code |
| section:medicationSection | S | 1..1 | BackboneElement | If both MedicationAdministration and MedicationRequest data are available, populate both resources. |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Medication use Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| text | S | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
| entry:medicationAdministration | 0..* | Reference(Medication Administration - Inpatient Med Admin) | A reference to data that supports this section | |
| entry:USCoreMedicationRequest | 0..* | Reference(US Core MedicationRequest Profile) | A reference to data that supports this section | |
| section:problemSection | S | 1..1 | BackboneElement | When the condition matches one of the codes in the Confirmed COVID-19 value set use the Observation - Laboratory SARS COVID-19 profile, when the condition matches one of the codes in the Suspected COVID-19 value set use the Observation - Laboratory SARS COVID-19 profile. For all other relevant conditions use the US Core Condition profile. |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Problem list Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| text | S | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | S | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:Condition | S | 1..* | Reference(Condition - Lab Confirmed COVID-19 | Condition - Suspected COVID-19 | US Core Condition Profile) | A reference to data that supports this section |
| section:resultSection | S | 1..1 | BackboneElement | When the lab test matches one of the codes in the SARS COVID-19 value set populate the Observation - Laboratory SARS COVID-19 profile. For all other relevant lab results, use the US Core Lab Result profile. |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Relevant diagnostic tests &or laboratory data Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| text | S | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | S | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:ObservationLab | S | 1..* | Reference(US Core Laboratory Result Observation Profile | Observation Laboratory SARS COVID-19) | A reference to data that supports this section |
| section:adverseEventSection | S | 0..1 | BackboneElement | Composition is broken into sections |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Adverse Event Section Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 85893-6 | |
| text | S | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Slices for entry | S | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:AdverseEvent | S | 1..* | Reference(AdverseEvent) | A reference to data that supports this section |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SΣ | 1..1 | Identifier | Version-independent identifier for the Composition |
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | SΣ | 1..1 | CodeableConcept | Medication administration.extended Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 87231-7 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the composition is about |
| encounter | SΣ | 1..1 | Reference(US Core Encounter Profile) | Context of the Composition |
| date | SΣ | 1..1 | dateTime | Composition editing time |
| author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
| title | Σ | 1..1 | string | Human Readable name/title |
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. |
| attester | 0..* | BackboneElement | Attests to accuracy of composition | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
| time | 0..1 | dateTime | When the composition was attested | |
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition |
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |
| target[x] | 1..1 | Target of the relationship | ||
| targetIdentifier | Identifier | |||
| targetReference | Reference(Composition) | |||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
| period | Σ | 0..1 | Period | The period covered by the documentation |
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
| Slices for section | SI | 1..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code |
| section:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:medicationSection | SI | 1..1 | BackboneElement | If both MedicationAdministration and MedicationRequest data are available, populate both resources. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Medication use Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | SI | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| Slices for entry | I | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:medicationAdministration | I | 0..* | Reference(Medication Administration - Inpatient Med Admin) | A reference to data that supports this section |
| entry:USCoreMedicationRequest | I | 0..* | Reference(US Core MedicationRequest Profile) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:problemSection | SI | 1..1 | BackboneElement | When the condition matches one of the codes in the Confirmed COVID-19 value set use the Observation - Laboratory SARS COVID-19 profile, when the condition matches one of the codes in the Suspected COVID-19 value set use the Observation - Laboratory SARS COVID-19 profile. For all other relevant conditions use the US Core Condition profile. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Problem list Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | SI | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| Slices for entry | SI | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:Condition | SI | 1..* | Reference(Condition - Lab Confirmed COVID-19 | Condition - Suspected COVID-19 | US Core Condition Profile) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:resultSection | SI | 1..1 | BackboneElement | When the lab test matches one of the codes in the SARS COVID-19 value set populate the Observation - Laboratory SARS COVID-19 profile. For all other relevant lab results, use the US Core Lab Result profile. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Relevant diagnostic tests &or laboratory data Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | SI | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| Slices for entry | SI | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:ObservationLab | SI | 1..* | Reference(US Core Laboratory Result Observation Profile | Observation Laboratory SARS COVID-19) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| section:adverseEventSection | SI | 0..1 | BackboneElement | Composition is broken into sections |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | S | 1..1 | CodeableConcept | Adverse Event Section Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 85893-6 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |
| text | SI | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |
| Slices for entry | SI | 1..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() |
| entry:AdverseEvent | SI | 1..* | Reference(AdverseEvent) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. |
| section | I | 0..* | See section (Composition) | Nested Section |
| Documentation for this format | ||||
Other representations of profile: CSV, Excel, Schematron
| Path | Conformance | ValueSet / Code |
| Composition.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | Pattern: LOINC code 87231-7 |
| Composition.category | example | DocumentClassValueSet |
| Composition.confidentiality | required | v3.ConfidentialityClassification |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.relatesTo.code | required | DocumentRelationshipType |
| Composition.event.code | example | ActCode |
| Composition.section.code | example | DocumentSectionCodes |
| Composition.section.mode | required | ListMode |
| Composition.section.orderedBy | preferred | ListOrderCodes |
| Composition.section.emptyReason | preferred | ListEmptyReasons |
| Composition.section:medicationSection.code | example | Pattern: LOINC code 10160-0 |
| Composition.section:medicationSection.mode | required | ListMode |
| Composition.section:medicationSection.orderedBy | preferred | ListOrderCodes |
| Composition.section:medicationSection.emptyReason | preferred | ListEmptyReasons |
| Composition.section:problemSection.code | example | Pattern: LOINC code 11450-4 |
| Composition.section:problemSection.mode | required | ListMode |
| Composition.section:problemSection.orderedBy | preferred | ListOrderCodes |
| Composition.section:problemSection.emptyReason | preferred | ListEmptyReasons |
| Composition.section:resultSection.code | example | Pattern: LOINC code 30954-2 |
| Composition.section:resultSection.mode | required | ListMode |
| Composition.section:resultSection.orderedBy | preferred | ListOrderCodes |
| Composition.section:resultSection.emptyReason | preferred | ListEmptyReasons |
| Composition.section:adverseEventSection.code | example | Pattern: LOINC code 85893-6 |
| Composition.section:adverseEventSection.mode | required | ListMode |
| Composition.section:adverseEventSection.orderedBy | preferred | ListOrderCodes |
| Composition.section:adverseEventSection.emptyReason | preferred | ListEmptyReasons |
| Id | Path | Details | Requirements |
| dom-2 | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | Composition.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.date | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.confidentiality | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.attester.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.attester.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester.time | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.attester.party | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.custodian | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.relatesTo | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.relatesTo.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.relatesTo.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.relatesTo.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.relatesTo.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.relatesTo.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.relatesTo.target[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.event.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.event.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.event.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.event.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.event.detail | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:medicationSection | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:medicationSection | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:medicationSection | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicationSection.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:medicationSection.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:medicationSection.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:medicationSection.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:medicationSection.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicationSection.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicationSection.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicationSection.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicationSection.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicationSection.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicationSection.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicationSection.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicationSection.entry:medicationAdministration | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicationSection.entry:USCoreMedicationRequest | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicationSection.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:medicationSection.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:problemSection | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:problemSection | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:problemSection | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problemSection.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:problemSection.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:problemSection.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:problemSection.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:problemSection.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problemSection.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problemSection.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problemSection.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problemSection.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problemSection.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problemSection.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problemSection.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problemSection.entry:Condition | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problemSection.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:problemSection.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:resultSection | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:resultSection | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:resultSection | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:resultSection.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:resultSection.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:resultSection.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:resultSection.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:resultSection.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:resultSection.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:resultSection.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:resultSection.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:resultSection.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:resultSection.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:resultSection.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:resultSection.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:resultSection.entry:ObservationLab | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:resultSection.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:resultSection.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| cmp-1 | Composition.section:adverseEventSection | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | Composition.section:adverseEventSection | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | Composition.section:adverseEventSection | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:adverseEventSection.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:adverseEventSection.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:adverseEventSection.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Composition.section:adverseEventSection.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Composition.section:adverseEventSection.title | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:adverseEventSection.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:adverseEventSection.author | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:adverseEventSection.focus | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:adverseEventSection.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:adverseEventSection.mode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:adverseEventSection.orderedBy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:adverseEventSection.entry | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:adverseEventSection.entry:AdverseEvent | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:adverseEventSection.emptyReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Composition.section:adverseEventSection.section | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
IG © 2020+ HL7 International - Pharmacy Work Group. Package hl7.fhir.us.nhsn-med-admin#1.0.0 based on FHIR 4.0.1. Generated 2021-10-12
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