United States Patient Care Summary (US-PCS) Implementation Guide
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United States Patient Care Summary (US-PCS) Implementation Guide - Downloaded Version 1.0.0 See the Directory of published versions

Resource Profile: Composition (US-PCS)

Official URL: http://hl7.org/fhir/us/pcs/StructureDefinition/Composition-us-pcs Version: 1.0.0
Standards status: Trial-use Maturity Level: 2 Computable Name: CompositionUsPcs
Other Identifiers: OID:2.16.840.1.113883.4.642.40.88.42.1

Copyright/Legal: HL7 International

A United States Patient Care Summary (US-PCS) is a FHIR document that captures key information for care transitions. It conforms to the International Patient Summary and is intended as a modern, streamlined summary that uses US Core resources to populate specific sections. The US-PCS profiles 7 sections (4 Must Support sections beyond the 3 mandatory) with a primary use case of providing a minimal, non-exhaustive summary that supports clinical decision-making at the point of care for both planned and unplanned care across organizational boundaries. The US-PCS conforms to the IPS but formally derives its Composition profile from the FHIR Clinical Documents Implementation Guide. The US-PCS definition of Must Support is provided in this guide although implementers should also refer to the US Core Implementation Guide definition of Must Support in the context of populating those resources.

Based on implementer feedback and historic precedence among C-CDA documents, an encounters section has been included in the US-PCS. Consequently, Composition.encounter and Composition.event[careProvisioningEvent].detail are not recommended for use in US-PCS. In US-PCS, encounter details are included in the Encounters section. The IPS FHIR Implementation Guide does not include a section for Encounters. A request has been made to the International Patient Summary Coordinating Committee to add an encounters section in future versions of the universal realm IPS guide.

Mandatory and Must Support Data Elements

The following data elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system and handled by the receiving system (see US-PCS Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and the formal summary, and definitions then follow.

Each US-PCS Composition Must Have:

  1. a status
  2. a type specifying that it is a patient summary
  3. a subject
  4. a date
  5. an author
  6. a title
  7. a confidentiality code
  8. a custodian (referencing a US Core Organization)
  9. Sections representing: allergies, medications and problems

Each US-PCS Composition Must Support:

  1. a textual narrative of the Composition (which does not include section content)
  2. extensions defined in FHIR Clinical Documents
  3. Sections representing: encounters, immunization, procedures and results

Profile Specific Implementation Guidance

This section provides detailed implementation guidance for the US-PCS Profile. The US-PCS Composition includes seven priority sections which is a subset of all sections profiled in the IPS FHIR Implementation Guide. Implementers may send additional sections so long as:

  • Each section SHALL include: a title, a code, a textual narrative of the data in the section (See IPS guide on Narrative).§comp-1
  • The corresponding US Core Implementation Guide resource SHALL be sent in a given section when available. For example, when sending a plan of care section (LOINC: 18776-5), US Core CarePlan Profile resources will be used when available. A list of sections with corresponding US Core resources are included in the Aligning US-PCS Sections with IPS, C-CDA and US Core table in this guide§comp-2
  • Each section SHALL contain a unique code to identify that section. For example, it would not be appropriate to send two separate Advance Directives sections (LOINC: 42348-3). This is enforced through the discriminator profiling on section.code§comp-3

The US-PCS General Guidance page includes the definition of Must Support for this guide and additional guidance on populating sections.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* ClinicalDocumentComposition US-PCS Composition
Constraints: clindoc-limit-participantType
... 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): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Required Pattern: en-US
... text S 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... extension:R5-Composition-version 0..1 string R5: An explicitly assigned identifer of a variation of the content in the Composition (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
Constraints: ext-1
.... extension:data-enterer 0..1 (Complex) A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension
.... extension:informant 0..* (Complex) An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension
.... extension:information-recipient 0..* (Complex) An Information Recipient is the intended recipient of the information at the time the document was created.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension
.... extension:participant S 0..* (Complex) A Participant that is not a data-enter, information-recipient nor an informant
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension
.... extension:consent 0..* Reference(Consent) consent
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension
.... extension:basedOn 0..* Reference(Resource) The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray.
URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
.... extension:change-made 0..1 (Complex) Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
.... Slices for extension Content/Rules for all slices
..... extension:R5-Composition-status 0..1 code This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status
Binding: R5CompositionStatusForR4 (0.1.0) (required): The workflow/clinical status of the composition.
Constraints: ext-1
... type SΣ 1..1 CodeableConcept Kind of composition (LOINC if possible)
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: 60591-5
..... 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
... Slices for category Σ 0..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by value:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:clinicalnotecategory Σ 0..1 CodeableConcept Category for Clinical Note
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.

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: 107903-7
...... display 1..1 string Representation defined by the system
Fixed Value: Clinical note
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(US Core Patient Profile) Who and/or what the composition is about
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... date SΣ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | Device | US Core Patient Profile | US Core RelatedPerson Profile | US Core Organization Profile) Who and/or what authored the composition
... title SΣ 1..1 string Human Readable name/title
... confidentiality SΣ 1..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... 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.
.... attester:legal_attester 0..1 BackboneElement aka legal authenticator
..... 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.
Required Pattern: legal
.... attester:professional_attester 0..* BackboneElement aka authenticator
..... 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.
Required Pattern: professional
... custodian SΣ 1..1 Reference(US Core Organization Profile) Organization which maintains the composition
... Slices for relatesTo 0..* BackboneElement Relationships to other compositions/documents
Slice: Unordered, Open by value:code, type:target
.... relatesTo:All Slices Content/Rules for all slices
..... 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.
..... Slices for target[x] 1..1 Target of the relationship
Slice: Unordered, Closed by type:$this
...... targetIdentifier Identifier
...... targetReference Reference(Composition | Composition (IPS) | Composition (US-PCS))
...... target[x]:targetIdentifier 0..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document
.... relatesTo:replaced_document 0..* BackboneElement The document(s) being superceded
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Required Pattern: replaces
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
..... Slices for target[x] Content/Rules for all slices
...... target[x]:targetIdentifier 1..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document
....... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
....... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
....... value Σ 1..1 string The value that is unique
Example General: 123456
.... relatesTo:appended_document 0..* BackboneElement The document(s) being appended too
..... 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.
Required Pattern: appends
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
..... Slices for target[x] Content/Rules for all slices
...... target[x]:targetIdentifier 1..1 Identifier Target of the relationship
....... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
... Slices for section SC 3..* BackboneElement Sections composing the US-PCS
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:sectionProblems SC 1..1 BackboneElement US-PCS Problems Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Condition | DocumentReference) Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:problem SC 0..* Reference(US Core Condition Problems and Health Concerns Profile) A reference to data that supports this section
..... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionAllergies SC 1..1 BackboneElement US-PCS Allergies and Intolerances Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 48765-2
....... 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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(AllergyIntolerance | DocumentReference) Relevant allergies or intolerances for that patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:allergyOrIntolerance SC 0..* Reference(US Core AllergyIntolerance Profile) A reference to data that supports this section
..... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionMedications SC 1..1 BackboneElement US-PCS Medication Summary Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) Medications relevant for the scope of the patient summary
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:medicationRequest SC 0..* Reference(US Core MedicationRequest Profile) A reference to data that supports this section
..... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionEncounters SC 0..1 BackboneElement US-PCS Encounters Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 46240-8
....... 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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Encounter | DocumentReference) Relevant encounters of the patient in the context of a patient summary.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:encounter SC 0..* Reference(US Core Encounter Profile) A reference to data that supports this section
.... section:sectionImmunizations SC 0..1 BackboneElement US-PCS Immunizations Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 11369-6
....... 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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Immunization | DocumentReference) Patient's immunization status and pertinent history.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:immunization SC 0..* Reference(US Core Immunization Profile) A reference to data that supports this section
.... section:sectionProceduresHx SC 0..1 BackboneElement US-PCS History of Procedures Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 47519-4
....... 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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Procedure | DocumentReference) Patient's past procedures pertinent to the scope of this document.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:procedure SC 0..* Reference(US Core Procedure Profile) A reference to data that supports this section
.... section:sectionResults SC 0..1 BackboneElement US-PCS Results Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Observation | DiagnosticReport | DocumentReference) Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:results-observation-lab-imaging SC 0..* Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) Observation results can include laboratory, imaging, microbiology/pathology, and other observations.
...... entry:results-diagnosticReport-lab-imaging-note SC 0..* Reference(US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core DiagnosticReport Profile for Report and Note Exchange) Diagnostic reports can include laboratory, imaging, clinical notes, impressions and other report data. These can reference other resources in the Bundle. References generally will not include large files in the summary (e.g. images would not be included).

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📍4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.category:clinicalnotecategory Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legal_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:professional_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProblems.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProblems.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionAllergies.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionAllergies.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionEncounters.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionImmunizations.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProceduresHx.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionResults.​code Base example Document Section Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
clindoc-limit-participantType error Composition The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()
cmp-1 error Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
cmp-uspcs-1 error Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults Either section.entry or emptyReason are present (entry.reference.exists() or emptyReason.exists())
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error 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 error 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 error Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error Composition.extension:R5-Composition-version, Composition.extension:data-enterer, Composition.extension:informant, Composition.extension:information-recipient, Composition.extension:participant, Composition.extension:consent, Composition.extension:basedOn, Composition.extension:change-made, Composition.modifierExtension, Composition.status.extension:R5-Composition-status, Composition.attester.modifierExtension, Composition.attester:legal_attester.modifierExtension, Composition.attester:professional_attester.modifierExtension, Composition.relatesTo.modifierExtension, Composition.relatesTo:replaced_document.modifierExtension, Composition.relatesTo:appended_document.modifierExtension, Composition.section.extension:change-made, Composition.section.extension:section-note, Composition.section.modifierExtension, Composition.section:sectionProblems.extension:change-made, Composition.section:sectionProblems.extension:section-note, Composition.section:sectionProblems.modifierExtension, Composition.section:sectionAllergies.extension:change-made, Composition.section:sectionAllergies.extension:section-note, Composition.section:sectionAllergies.modifierExtension, Composition.section:sectionMedications.extension:change-made, Composition.section:sectionMedications.extension:section-note, Composition.section:sectionMedications.modifierExtension, Composition.section:sectionEncounters.extension:change-made, Composition.section:sectionEncounters.extension:section-note, Composition.section:sectionEncounters.modifierExtension, Composition.section:sectionImmunizations.extension:change-made, Composition.section:sectionImmunizations.extension:section-note, Composition.section:sectionImmunizations.modifierExtension, Composition.section:sectionProceduresHx.extension:change-made, Composition.section:sectionProceduresHx.extension:section-note, Composition.section:sectionProceduresHx.modifierExtension, Composition.section:sectionResults.extension:change-made, Composition.section:sectionResults.extension:section-note, Composition.section:sectionResults.modifierExtension Must have either extensions or value[x], not both extension.exists() != value.exists()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* ClinicalDocumentComposition US-PCS Composition
... language 0..1 code Language of the resource content
Required Pattern: en-US
... type 1..1 CodeableConcept Kind of composition (LOINC if possible)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 60591-5
... subject 1..1 Reference(US Core Patient Profile) Who and/or what the composition is about
.... reference S 1..1 string Literal reference, Relative, internal or absolute URL
... confidentiality S 1..1 code As defined by affinity domain
... custodian 1..1 Reference(US Core Organization Profile) Organization which maintains the composition
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition | Composition (IPS) | Composition (US-PCS))
... Slices for section 3..* BackboneElement Sections composing the US-PCS
Slice: Unordered, Open by value:code
.... section:All Slices Content/Rules for all slices
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
..... text 1..1 Narrative Text summary of the section, for human interpretation
..... section 0..0 Nested Section
.... section:sectionProblems SC 1..1 BackboneElement US-PCS Problems Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11450-4
..... Slices for entry 0..* Reference(Condition | DocumentReference) Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:problem S 0..* Reference(US Core Condition Problems and Health Concerns Profile) A reference to data that supports this section
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionAllergies SC 1..1 BackboneElement US-PCS Allergies and Intolerances Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48765-2
..... Slices for entry 0..* Reference(AllergyIntolerance | DocumentReference) Relevant allergies or intolerances for that patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:allergyOrIntolerance S 0..* Reference(US Core AllergyIntolerance Profile) A reference to data that supports this section
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionMedications SC 1..1 BackboneElement US-PCS Medication Summary Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
..... Slices for entry 0..* Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) Medications relevant for the scope of the patient summary
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:medicationRequest S 0..* Reference(US Core MedicationRequest Profile) A reference to data that supports this section
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionEncounters SC 0..1 BackboneElement US-PCS Encounters Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46240-8
..... Slices for entry 0..* Reference(Encounter | DocumentReference) Relevant encounters of the patient in the context of a patient summary.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:encounter S 0..* Reference(US Core Encounter Profile) A reference to data that supports this section
.... section:sectionImmunizations SC 0..1 BackboneElement US-PCS Immunizations Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11369-6
..... Slices for entry 0..* Reference(Immunization | DocumentReference) Patient's immunization status and pertinent history.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:immunization S 0..* Reference(US Core Immunization Profile) A reference to data that supports this section
.... section:sectionProceduresHx SC 0..1 BackboneElement US-PCS History of Procedures Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
..... Slices for entry 0..* Reference(Procedure | DocumentReference) Patient's past procedures pertinent to the scope of this document.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:procedure S 0..* Reference(US Core Procedure Profile) A reference to data that supports this section
.... section:sectionResults SC 0..1 BackboneElement US-PCS Results Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
..... Slices for entry 0..* Reference(Observation | DiagnosticReport | DocumentReference) Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:results-observation-lab-imaging S 0..* Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) Observation results can include laboratory, imaging, microbiology/pathology, and other observations.
...... entry:results-diagnosticReport-lab-imaging-note S 0..* Reference(US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core DiagnosticReport Profile for Report and Note Exchange) Diagnostic reports can include laboratory, imaging, clinical notes, impressions and other report data. These can reference other resources in the Bundle. References generally will not include large files in the summary (e.g. images would not be included).

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
cmp-uspcs-1 error Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults Either section.entry or emptyReason are present (entry.reference.exists() or emptyReason.exists())
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* ClinicalDocumentComposition US-PCS Composition
Constraints: clindoc-limit-participantType
... id Σ 0..1 id 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
... text S 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:R5-Composition-version 0..1 string R5: An explicitly assigned identifer of a variation of the content in the Composition (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
Constraints: ext-1
.... extension:data-enterer 0..1 (Complex) A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension
.... extension:informant 0..* (Complex) An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension
.... extension:information-recipient 0..* (Complex) An Information Recipient is the intended recipient of the information at the time the document was created.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension
.... extension:participant S 0..* (Complex) A Participant that is not a data-enter, information-recipient nor an informant
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension
.... extension:consent 0..* Reference(Consent) consent
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension
.... extension:basedOn 0..* Reference(Resource) The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray.
URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
.... extension:change-made 0..1 (Complex) Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..1 Identifier Version-independent identifier for the Composition
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
.... id 0..1 string xml:id (or equivalent in JSON)
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:R5-Composition-status 0..1 code This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status
Binding: R5CompositionStatusForR4 (0.1.0) (required): The workflow/clinical status of the composition.
Constraints: ext-1
.... value 0..1 string Primitive value for code
... type SΣ 1..1 CodeableConcept Kind of composition (LOINC if possible)
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: 60591-5
..... 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
... Slices for category Σ 0..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by value:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:clinicalnotecategory Σ 0..1 CodeableConcept Category for Clinical Note
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.

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: 107903-7
...... display 1..1 string Representation defined by the system
Fixed Value: Clinical note
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(US Core Patient Profile) Who and/or what the composition is about
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter Σ 0..1 Reference(Encounter) Context of the Composition
... date SΣ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | Device | US Core Patient Profile | US Core RelatedPerson Profile | US Core Organization Profile) Who and/or what authored the composition
... title SΣ 1..1 string Human Readable name/title
... confidentiality SΣ 1..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester: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
..... 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
.... attester:legal_attester 0..1 BackboneElement aka legal authenticator
..... 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.
Required Pattern: legal
..... time 0..1 dateTime When the composition was attested
..... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
.... attester:professional_attester 0..* BackboneElement aka authenticator
..... 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.
Required Pattern: professional
..... time 0..1 dateTime When the composition was attested
..... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
... custodian SΣ 1..1 Reference(US Core Organization Profile) Organization which maintains the composition
... Slices for relatesTo 0..* BackboneElement Relationships to other compositions/documents
Slice: Unordered, Open by value:code, type:target
.... relatesTo: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
..... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
..... Slices for target[x] 1..1 Target of the relationship
Slice: Unordered, Closed by type:$this
...... targetIdentifier Identifier
...... targetReference Reference(Composition | Composition (IPS) | Composition (US-PCS))
...... target[x]:targetIdentifier 0..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document
.... relatesTo:replaced_document 0..* BackboneElement The document(s) being superceded
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Required Pattern: replaces
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
..... Slices for target[x] Content/Rules for all slices
...... target[x]:targetIdentifier 1..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
....... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
....... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
....... value Σ 1..1 string The value that is unique
Example General: 123456
....... period Σ 0..1 Period Time period when id is/was valid for use
....... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... relatesTo:appended_document 0..* BackboneElement The document(s) being appended too
..... 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.
Required Pattern: appends
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
..... Slices for target[x] Content/Rules for all slices
...... target[x]:targetIdentifier 1..1 Identifier Target of the relationship
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
....... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
....... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
....... value Σ 0..1 string The value that is unique
Example General: 123456
....... period Σ 0..1 Period Time period when id is/was valid for use
....... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... 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: ActCode (3.0.0) (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 SC 3..* BackboneElement Sections composing the US-PCS
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionProblems SC 1..1 BackboneElement US-PCS Problems Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(Condition | DocumentReference) Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:problem SC 0..* Reference(US Core Condition Problems and Health Concerns Profile) A reference to data that supports this section
..... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionAllergies SC 1..1 BackboneElement US-PCS Allergies and Intolerances Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 48765-2
....... 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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(AllergyIntolerance | DocumentReference) Relevant allergies or intolerances for that patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:allergyOrIntolerance SC 0..* Reference(US Core AllergyIntolerance Profile) A reference to data that supports this section
..... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionMedications SC 1..1 BackboneElement US-PCS Medication Summary Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) Medications relevant for the scope of the patient summary
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:medicationRequest SC 0..* Reference(US Core MedicationRequest Profile) A reference to data that supports this section
..... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionEncounters SC 0..1 BackboneElement US-PCS Encounters Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 46240-8
....... 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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(Encounter | DocumentReference) Relevant encounters of the patient in the context of a patient summary.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:encounter SC 0..* Reference(US Core Encounter Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionImmunizations SC 0..1 BackboneElement US-PCS Immunizations Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 11369-6
....... 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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(Immunization | DocumentReference) Patient's immunization status and pertinent history.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:immunization SC 0..* Reference(US Core Immunization Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionProceduresHx SC 0..1 BackboneElement US-PCS History of Procedures Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 47519-4
....... 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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(Procedure | DocumentReference) Patient's past procedures pertinent to the scope of this document.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:procedure SC 0..* Reference(US Core Procedure Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionResults SC 0..1 BackboneElement US-PCS Results Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(Observation | DiagnosticReport | DocumentReference) Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:results-observation-lab-imaging SC 0..* Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) Observation results can include laboratory, imaging, microbiology/pathology, and other observations.
...... entry:results-diagnosticReport-lab-imaging-note SC 0..* Reference(US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core DiagnosticReport Profile for Report and Note Exchange) Diagnostic reports can include laboratory, imaging, clinical notes, impressions and other report data. These can reference other resources in the Bundle. References generally will not include large files in the summary (e.g. images would not be included).
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📍4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.category:clinicalnotecategory Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.subject.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legal_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:professional_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
Composition.event.code Base example v3 Code System ActCode 📍3.0.0 THO v7.3
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionProblems.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProblems.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionProblems.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProblems.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionAllergies.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionAllergies.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionAllergies.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionAllergies.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionEncounters.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionEncounters.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionEncounters.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionEncounters.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionImmunizations.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionImmunizations.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionImmunizations.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionImmunizations.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionProceduresHx.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProceduresHx.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionProceduresHx.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProceduresHx.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionResults.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionResults.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionResults.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionResults.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
clindoc-limit-participantType error Composition The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()
cmp-1 error Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
cmp-uspcs-1 error Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults Either section.entry or emptyReason are present (entry.reference.exists() or emptyReason.exists())
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error 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 error 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 error Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Summary

Mandatory: 7 elements(1 nested mandatory element)
Must-Support: 20 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Composition.section
  • The element 1 is sliced based on the value of Composition.section.entry

Maturity: 2

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* ClinicalDocumentComposition US-PCS Composition
Constraints: clindoc-limit-participantType
... 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): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Required Pattern: en-US
... text S 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... extension:R5-Composition-version 0..1 string R5: An explicitly assigned identifer of a variation of the content in the Composition (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
Constraints: ext-1
.... extension:data-enterer 0..1 (Complex) A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension
.... extension:informant 0..* (Complex) An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension
.... extension:information-recipient 0..* (Complex) An Information Recipient is the intended recipient of the information at the time the document was created.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension
.... extension:participant S 0..* (Complex) A Participant that is not a data-enter, information-recipient nor an informant
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension
.... extension:consent 0..* Reference(Consent) consent
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension
.... extension:basedOn 0..* Reference(Resource) The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray.
URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
.... extension:change-made 0..1 (Complex) Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
.... Slices for extension Content/Rules for all slices
..... extension:R5-Composition-status 0..1 code This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status
Binding: R5CompositionStatusForR4 (0.1.0) (required): The workflow/clinical status of the composition.
Constraints: ext-1
... type SΣ 1..1 CodeableConcept Kind of composition (LOINC if possible)
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: 60591-5
..... 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
... Slices for category Σ 0..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by value:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:clinicalnotecategory Σ 0..1 CodeableConcept Category for Clinical Note
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.

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: 107903-7
...... display 1..1 string Representation defined by the system
Fixed Value: Clinical note
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(US Core Patient Profile) Who and/or what the composition is about
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... date SΣ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | Device | US Core Patient Profile | US Core RelatedPerson Profile | US Core Organization Profile) Who and/or what authored the composition
... title SΣ 1..1 string Human Readable name/title
... confidentiality SΣ 1..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... 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.
.... attester:legal_attester 0..1 BackboneElement aka legal authenticator
..... 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.
Required Pattern: legal
.... attester:professional_attester 0..* BackboneElement aka authenticator
..... 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.
Required Pattern: professional
... custodian SΣ 1..1 Reference(US Core Organization Profile) Organization which maintains the composition
... Slices for relatesTo 0..* BackboneElement Relationships to other compositions/documents
Slice: Unordered, Open by value:code, type:target
.... relatesTo:All Slices Content/Rules for all slices
..... 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.
..... Slices for target[x] 1..1 Target of the relationship
Slice: Unordered, Closed by type:$this
...... targetIdentifier Identifier
...... targetReference Reference(Composition | Composition (IPS) | Composition (US-PCS))
...... target[x]:targetIdentifier 0..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document
.... relatesTo:replaced_document 0..* BackboneElement The document(s) being superceded
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Required Pattern: replaces
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
..... Slices for target[x] Content/Rules for all slices
...... target[x]:targetIdentifier 1..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document
....... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
....... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
....... value Σ 1..1 string The value that is unique
Example General: 123456
.... relatesTo:appended_document 0..* BackboneElement The document(s) being appended too
..... 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.
Required Pattern: appends
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
..... Slices for target[x] Content/Rules for all slices
...... target[x]:targetIdentifier 1..1 Identifier Target of the relationship
....... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
... Slices for section SC 3..* BackboneElement Sections composing the US-PCS
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:sectionProblems SC 1..1 BackboneElement US-PCS Problems Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Condition | DocumentReference) Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:problem SC 0..* Reference(US Core Condition Problems and Health Concerns Profile) A reference to data that supports this section
..... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionAllergies SC 1..1 BackboneElement US-PCS Allergies and Intolerances Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 48765-2
....... 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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(AllergyIntolerance | DocumentReference) Relevant allergies or intolerances for that patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:allergyOrIntolerance SC 0..* Reference(US Core AllergyIntolerance Profile) A reference to data that supports this section
..... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionMedications SC 1..1 BackboneElement US-PCS Medication Summary Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) Medications relevant for the scope of the patient summary
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:medicationRequest SC 0..* Reference(US Core MedicationRequest Profile) A reference to data that supports this section
..... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionEncounters SC 0..1 BackboneElement US-PCS Encounters Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 46240-8
....... 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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Encounter | DocumentReference) Relevant encounters of the patient in the context of a patient summary.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:encounter SC 0..* Reference(US Core Encounter Profile) A reference to data that supports this section
.... section:sectionImmunizations SC 0..1 BackboneElement US-PCS Immunizations Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 11369-6
....... 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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Immunization | DocumentReference) Patient's immunization status and pertinent history.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:immunization SC 0..* Reference(US Core Immunization Profile) A reference to data that supports this section
.... section:sectionProceduresHx SC 0..1 BackboneElement US-PCS History of Procedures Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 47519-4
....... 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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Procedure | DocumentReference) Patient's past procedures pertinent to the scope of this document.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:procedure SC 0..* Reference(US Core Procedure Profile) A reference to data that supports this section
.... section:sectionResults SC 0..1 BackboneElement US-PCS Results Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(Observation | DiagnosticReport | DocumentReference) Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:results-observation-lab-imaging SC 0..* Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) Observation results can include laboratory, imaging, microbiology/pathology, and other observations.
...... entry:results-diagnosticReport-lab-imaging-note SC 0..* Reference(US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core DiagnosticReport Profile for Report and Note Exchange) Diagnostic reports can include laboratory, imaging, clinical notes, impressions and other report data. These can reference other resources in the Bundle. References generally will not include large files in the summary (e.g. images would not be included).

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📍4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.category:clinicalnotecategory Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legal_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:professional_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProblems.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProblems.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionAllergies.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionAllergies.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionEncounters.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionImmunizations.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProceduresHx.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionResults.​code Base example Document Section Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
clindoc-limit-participantType error Composition The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()
cmp-1 error Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
cmp-uspcs-1 error Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults Either section.entry or emptyReason are present (entry.reference.exists() or emptyReason.exists())
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error 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 error 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 error Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error Composition.extension:R5-Composition-version, Composition.extension:data-enterer, Composition.extension:informant, Composition.extension:information-recipient, Composition.extension:participant, Composition.extension:consent, Composition.extension:basedOn, Composition.extension:change-made, Composition.modifierExtension, Composition.status.extension:R5-Composition-status, Composition.attester.modifierExtension, Composition.attester:legal_attester.modifierExtension, Composition.attester:professional_attester.modifierExtension, Composition.relatesTo.modifierExtension, Composition.relatesTo:replaced_document.modifierExtension, Composition.relatesTo:appended_document.modifierExtension, Composition.section.extension:change-made, Composition.section.extension:section-note, Composition.section.modifierExtension, Composition.section:sectionProblems.extension:change-made, Composition.section:sectionProblems.extension:section-note, Composition.section:sectionProblems.modifierExtension, Composition.section:sectionAllergies.extension:change-made, Composition.section:sectionAllergies.extension:section-note, Composition.section:sectionAllergies.modifierExtension, Composition.section:sectionMedications.extension:change-made, Composition.section:sectionMedications.extension:section-note, Composition.section:sectionMedications.modifierExtension, Composition.section:sectionEncounters.extension:change-made, Composition.section:sectionEncounters.extension:section-note, Composition.section:sectionEncounters.modifierExtension, Composition.section:sectionImmunizations.extension:change-made, Composition.section:sectionImmunizations.extension:section-note, Composition.section:sectionImmunizations.modifierExtension, Composition.section:sectionProceduresHx.extension:change-made, Composition.section:sectionProceduresHx.extension:section-note, Composition.section:sectionProceduresHx.modifierExtension, Composition.section:sectionResults.extension:change-made, Composition.section:sectionResults.extension:section-note, Composition.section:sectionResults.modifierExtension Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* ClinicalDocumentComposition US-PCS Composition
... language 0..1 code Language of the resource content
Required Pattern: en-US
... type 1..1 CodeableConcept Kind of composition (LOINC if possible)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 60591-5
... subject 1..1 Reference(US Core Patient Profile) Who and/or what the composition is about
.... reference S 1..1 string Literal reference, Relative, internal or absolute URL
... confidentiality S 1..1 code As defined by affinity domain
... custodian 1..1 Reference(US Core Organization Profile) Organization which maintains the composition
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition | Composition (IPS) | Composition (US-PCS))
... Slices for section 3..* BackboneElement Sections composing the US-PCS
Slice: Unordered, Open by value:code
.... section:All Slices Content/Rules for all slices
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
..... text 1..1 Narrative Text summary of the section, for human interpretation
..... section 0..0 Nested Section
.... section:sectionProblems SC 1..1 BackboneElement US-PCS Problems Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11450-4
..... Slices for entry 0..* Reference(Condition | DocumentReference) Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:problem S 0..* Reference(US Core Condition Problems and Health Concerns Profile) A reference to data that supports this section
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionAllergies SC 1..1 BackboneElement US-PCS Allergies and Intolerances Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48765-2
..... Slices for entry 0..* Reference(AllergyIntolerance | DocumentReference) Relevant allergies or intolerances for that patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:allergyOrIntolerance S 0..* Reference(US Core AllergyIntolerance Profile) A reference to data that supports this section
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionMedications SC 1..1 BackboneElement US-PCS Medication Summary Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
..... Slices for entry 0..* Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) Medications relevant for the scope of the patient summary
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:medicationRequest S 0..* Reference(US Core MedicationRequest Profile) A reference to data that supports this section
..... emptyReason S 0..1 CodeableConcept Why the section is empty
.... section:sectionEncounters SC 0..1 BackboneElement US-PCS Encounters Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46240-8
..... Slices for entry 0..* Reference(Encounter | DocumentReference) Relevant encounters of the patient in the context of a patient summary.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:encounter S 0..* Reference(US Core Encounter Profile) A reference to data that supports this section
.... section:sectionImmunizations SC 0..1 BackboneElement US-PCS Immunizations Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11369-6
..... Slices for entry 0..* Reference(Immunization | DocumentReference) Patient's immunization status and pertinent history.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:immunization S 0..* Reference(US Core Immunization Profile) A reference to data that supports this section
.... section:sectionProceduresHx SC 0..1 BackboneElement US-PCS History of Procedures Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
..... Slices for entry 0..* Reference(Procedure | DocumentReference) Patient's past procedures pertinent to the scope of this document.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:procedure S 0..* Reference(US Core Procedure Profile) A reference to data that supports this section
.... section:sectionResults SC 0..1 BackboneElement US-PCS Results Section
Constraints: cmp-uspcs-1
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
..... Slices for entry 0..* Reference(Observation | DiagnosticReport | DocumentReference) Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:results-observation-lab-imaging S 0..* Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) Observation results can include laboratory, imaging, microbiology/pathology, and other observations.
...... entry:results-diagnosticReport-lab-imaging-note S 0..* Reference(US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core DiagnosticReport Profile for Report and Note Exchange) Diagnostic reports can include laboratory, imaging, clinical notes, impressions and other report data. These can reference other resources in the Bundle. References generally will not include large files in the summary (e.g. images would not be included).

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
cmp-uspcs-1 error Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults Either section.entry or emptyReason are present (entry.reference.exists() or emptyReason.exists())

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* ClinicalDocumentComposition US-PCS Composition
Constraints: clindoc-limit-participantType
... id Σ 0..1 id 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
... text S 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:R5-Composition-version 0..1 string R5: An explicitly assigned identifer of a variation of the content in the Composition (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
Constraints: ext-1
.... extension:data-enterer 0..1 (Complex) A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension
.... extension:informant 0..* (Complex) An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension
.... extension:information-recipient 0..* (Complex) An Information Recipient is the intended recipient of the information at the time the document was created.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension
.... extension:participant S 0..* (Complex) A Participant that is not a data-enter, information-recipient nor an informant
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension
.... extension:consent 0..* Reference(Consent) consent
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension
.... extension:basedOn 0..* Reference(Resource) The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray.
URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
.... extension:change-made 0..1 (Complex) Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..1 Identifier Version-independent identifier for the Composition
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
.... id 0..1 string xml:id (or equivalent in JSON)
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:R5-Composition-status 0..1 code This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status
Binding: R5CompositionStatusForR4 (0.1.0) (required): The workflow/clinical status of the composition.
Constraints: ext-1
.... value 0..1 string Primitive value for code
... type SΣ 1..1 CodeableConcept Kind of composition (LOINC if possible)
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: 60591-5
..... 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
... Slices for category Σ 0..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by value:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:clinicalnotecategory Σ 0..1 CodeableConcept Category for Clinical Note
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.

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: 107903-7
...... display 1..1 string Representation defined by the system
Fixed Value: Clinical note
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(US Core Patient Profile) Who and/or what the composition is about
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter Σ 0..1 Reference(Encounter) Context of the Composition
... date SΣ 1..1 dateTime Composition editing time
... author SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | Device | US Core Patient Profile | US Core RelatedPerson Profile | US Core Organization Profile) Who and/or what authored the composition
... title SΣ 1..1 string Human Readable name/title
... confidentiality SΣ 1..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester: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
..... 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
.... attester:legal_attester 0..1 BackboneElement aka legal authenticator
..... 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.
Required Pattern: legal
..... time 0..1 dateTime When the composition was attested
..... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
.... attester:professional_attester 0..* BackboneElement aka authenticator
..... 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.
Required Pattern: professional
..... time 0..1 dateTime When the composition was attested
..... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
... custodian SΣ 1..1 Reference(US Core Organization Profile) Organization which maintains the composition
... Slices for relatesTo 0..* BackboneElement Relationships to other compositions/documents
Slice: Unordered, Open by value:code, type:target
.... relatesTo: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
..... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
..... Slices for target[x] 1..1 Target of the relationship
Slice: Unordered, Closed by type:$this
...... targetIdentifier Identifier
...... targetReference Reference(Composition | Composition (IPS) | Composition (US-PCS))
...... target[x]:targetIdentifier 0..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document
.... relatesTo:replaced_document 0..* BackboneElement The document(s) being superceded
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Required Pattern: replaces
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
..... Slices for target[x] Content/Rules for all slices
...... target[x]:targetIdentifier 1..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
....... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
....... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
....... value Σ 1..1 string The value that is unique
Example General: 123456
....... period Σ 0..1 Period Time period when id is/was valid for use
....... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... relatesTo:appended_document 0..* BackboneElement The document(s) being appended too
..... 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.
Required Pattern: appends
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
..... Slices for target[x] Content/Rules for all slices
...... target[x]:targetIdentifier 1..1 Identifier Target of the relationship
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
....... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
....... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
....... value Σ 0..1 string The value that is unique
Example General: 123456
....... period Σ 0..1 Period Time period when id is/was valid for use
....... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... 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: ActCode (3.0.0) (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 SC 3..* BackboneElement Sections composing the US-PCS
Slice: Unordered, Open by value:code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionProblems SC 1..1 BackboneElement US-PCS Problems Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(Condition | DocumentReference) Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:problem SC 0..* Reference(US Core Condition Problems and Health Concerns Profile) A reference to data that supports this section
..... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionAllergies SC 1..1 BackboneElement US-PCS Allergies and Intolerances Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 48765-2
....... 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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(AllergyIntolerance | DocumentReference) Relevant allergies or intolerances for that patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:allergyOrIntolerance SC 0..* Reference(US Core AllergyIntolerance Profile) A reference to data that supports this section
..... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionMedications SC 1..1 BackboneElement US-PCS Medication Summary Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) Medications relevant for the scope of the patient summary
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:medicationRequest SC 0..* Reference(US Core MedicationRequest Profile) A reference to data that supports this section
..... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionEncounters SC 0..1 BackboneElement US-PCS Encounters Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 46240-8
....... 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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(Encounter | DocumentReference) Relevant encounters of the patient in the context of a patient summary.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:encounter SC 0..* Reference(US Core Encounter Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionImmunizations SC 0..1 BackboneElement US-PCS Immunizations Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 11369-6
....... 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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(Immunization | DocumentReference) Patient's immunization status and pertinent history.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:immunization SC 0..* Reference(US Core Immunization Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionProceduresHx SC 0..1 BackboneElement US-PCS History of Procedures Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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: 47519-4
....... 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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(Procedure | DocumentReference) Patient's past procedures pertinent to the scope of this document.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:procedure SC 0..* Reference(US Core Procedure Profile) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:sectionResults SC 0..1 BackboneElement US-PCS Results Section
Constraints: cmp-1, cmp-2, cmp-uspcs-1
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... 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 Classification of section (recommended)
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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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 C 0..* Reference(Observation | DiagnosticReport | DocumentReference) Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.
Slice: Unordered, Open by profile:resolve()
..... Slices for entry Content/Rules for all slices
...... entry:results-observation-lab-imaging SC 0..* Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) Observation results can include laboratory, imaging, microbiology/pathology, and other observations.
...... entry:results-diagnosticReport-lab-imaging-note SC 0..* Reference(US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core DiagnosticReport Profile for Report and Note Exchange) Diagnostic reports can include laboratory, imaging, clinical notes, impressions and other report data. These can reference other resources in the Bundle. References generally will not include large files in the summary (e.g. images would not be included).
..... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📍4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.category:clinicalnotecategory Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.subject.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legal_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:professional_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
Composition.event.code Base example v3 Code System ActCode 📍3.0.0 THO v7.3
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionProblems.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProblems.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionProblems.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProblems.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionAllergies.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionAllergies.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionAllergies.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionAllergies.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionEncounters.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionEncounters.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionEncounters.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionEncounters.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionImmunizations.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionImmunizations.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionImmunizations.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionImmunizations.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionProceduresHx.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProceduresHx.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionProceduresHx.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionProceduresHx.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:sectionResults.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:sectionResults.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionResults.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:sectionResults.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
clindoc-limit-participantType error Composition The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()
cmp-1 error Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section, Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
cmp-uspcs-1 error Composition.section:sectionProblems, Composition.section:sectionAllergies, Composition.section:sectionMedications, Composition.section:sectionEncounters, Composition.section:sectionImmunizations, Composition.section:sectionProceduresHx, Composition.section:sectionResults Either section.entry or emptyReason are present (entry.reference.exists() or emptyReason.exists())
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error 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 error 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 error Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Summary

Mandatory: 7 elements(1 nested mandatory element)
Must-Support: 20 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Composition.section
  • The element 1 is sliced based on the value of Composition.section.entry

Maturity: 2

 

Other representations of profile: CSV, Excel, Schematron