| MII_PR_Bildgebung_Semistrukt_Befundbericht (Composition) | I | | Composition | There are no (further) constraints on this element Element idShort description A set of resources composed into a single coherent clinical statement with clinical attestation Definition A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).
While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
Composition Constraints- dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty() - dom-4: 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-3: 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-6: A resource should have narrative for robust management
text.`div`.exists() - dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty()
- rim: Entity. Role, or Act
- workflow: Event
- rim: Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
- cda: ClinicalDocument
- fhirdocumentreference: when described by DocumentReference
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| id | S Σ | 0..1 | string | There are no (further) constraints on this element Element idShort description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
string |
| meta | S Σ | 0..1 | Meta | There are no (further) constraints on this element Element idShort description Metadata about the resource Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Meta Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.meta.extension Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
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| versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idComposition.meta.versionId Version specific identifier Definition The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
id Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element idComposition.meta.lastUpdated When the resource version last changed Definition When the resource last changed - e.g. when the version changed.
This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
instant Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| source | S Σ | 0..1 | uri | There are no (further) constraints on this element Element idShort description Identifies where the resource comes from Definition A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.
This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| profile | S Σ | 0..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element idShort description Profiles this resource claims to conform to Definition Comments It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
canonical(StructureDefinition) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idComposition.meta.security Security Labels applied to this resource Definition Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Coding Binding Security Labels from the Healthcare Privacy and Security Classification System.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
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| tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element idShort description Tags applied to this resource Definition Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Coding Binding Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idComposition.implicitRules A set of rules under which this content was created Definition A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| language | | 0..1 | codeBinding | There are no (further) constraints on this element Element idShort description Language of the resource content Definition The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
code Binding CommonLanguages (preferred)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| text | | 0..1 | Narrative | There are no (further) constraints on this element Element idShort description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Narrative Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: N/A
- rim: Act.text?
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| contained | | 0..* | Resource | There are no (further) constraints on this element Element idShort description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Resource Mappings- rim: Entity. Role, or Act
- rim: N/A
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| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idShort description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
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| modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.modifierExtension Extensions that cannot be ignored Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idShort description Version-independent identifier for the Composition Definition A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.
Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.
Identifier Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
- rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
- servd: Identifier
- workflow: Event.identifier
- w5: FiveWs.identifier
- rim: Document.id / Document.setId
- cda: .setId
- fhirdocumentreference: DocumentReference.masterIdentifier
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| status | S Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idShort description preliminary | final | amended | entered-in-error Definition The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.
Need to be able to mark interim, amended, or withdrawn compositions or documents.
If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements.
Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.
code Binding The workflow/clinical status of the composition.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- workflow: Event.status
- w5: FiveWs.status
- rim: interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
- cda: n/a
- fhirdocumentreference: DocumentReference.status
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| type | S Σ | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idShort description Kind of composition (LOINC if possible) Definition Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition.
Key metadata element describing the composition, used in searching/filtering.
For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.
CodeableConcept Binding FHIRDocumentTypeCodes (preferred)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- workflow: Event.code
- w5: FiveWs.class
- rim: ./code
- cda: .code
- fhirdocumentreference: DocumentReference.type
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| category | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idShort description Categorization of Composition Definition A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.
Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.
This is a metadata field from XDS/MHD.
CodeableConcept Binding High-level kind of a clinical document at a macro level.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- workflow: Event.subject
- w5: FiveWs.class
- rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
- cda: n/a
- fhirdocumentreference: DocumenttReference.category
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| subject | S Σ I | 0..1 | Reference(Patient) | Element idShort description Who and/or what the composition is about Definition Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).
Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.
For clinical documents, this is usually the patient.
Reference(Patient) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- w5: FiveWs.subject[x]
- rim: .participation[typeCode="SBJ"].role[typeCode="PAT"]
- cda: .recordTarget
- fhirdocumentreference: DocumentReference.subject
- w5: FiveWs.subject
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| encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idShort description Context of the Composition Definition Describes the clinical encounter or type of care this documentation is associated with.
Provides context for the composition and supports searching.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Encounter) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Event.context
- w5: FiveWs.context
- rim: unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
- cda: .componentOf.encompassingEncounter
- fhirdocumentreference: DocumentReference.context.encounter
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| date | S Σ | 1..1 | dateTime | There are no (further) constraints on this element Element idShort description Composition editing time Definition The composition editing time, when the composition was last logically changed by the author.
dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.
The Last Modified Date on the composition may be after the date of the document was attested without being changed.
dateTime Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- workflow: Event.occurrence[x]
- w5: FiveWs.done[x]
- rim: .effectiveTime[type="TS"]
- cda: .effectiveTime
- fhirdocumentreference: DocumentReference.content.attachment.date, DocumentReference.created
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| author | S Σ I | 1..* | Reference(Practitioner) | Element idShort description Who and/or what authored the composition Definition Identifies who is responsible for the information in the composition, not necessarily who typed it in.
Identifies who is responsible for the content.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Practitioner) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Event.performer
- w5: FiveWs.author
- rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
- cda: .author.assignedAuthor
- fhirdocumentreference: DocumentReference.agent
|
| title | S Σ | 1..1 | string | There are no (further) constraints on this element Element idShort description Human Readable name/title Definition Official human-readable label for the composition.
For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: ./title
- cda: .title
- fhirdocumentreference: DocumentReference.description, DocumentReference.content.attachment.title
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| confidentiality | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.confidentiality As defined by affinity domain Definition The code specifying the level of confidentiality of the Composition.
The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not.
code Binding Codes specifying the level of confidentiality of the composition.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: .confidentialityCode
- cda: .confidentialityCode
- fhirdocumentreference: DocumentReference.securityLabel
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| attester | | 0..* | BackboneElement | There are no (further) constraints on this element Element idShort description Attests to accuracy of composition Definition A participant who has attested to the accuracy of the composition/document.
Identifies responsibility for the accuracy of the composition content.
Only list each attester once.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
- cda: .authenticator/.legalAuthenticator
- fhirdocumentreference: DocumentReference.authenticator
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| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.attester.extension Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.attester.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
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| mode | | 1..1 | codeBinding | There are no (further) constraints on this element Element idComposition.attester.mode personal | professional | legal | official Definition The type of attestation the authenticator offers.
Indicates the level of authority of the attestation.
Note that FHIR strings SHALL NOT exceed 1MB in size
code Binding The way in which a person authenticated a composition.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: unique(./modeCode)
- cda: implied by .authenticator/.legalAuthenticator
|
| time | | 0..1 | dateTime | There are no (further) constraints on this element Element idComposition.attester.time When the composition was attested Definition When the composition was attested by the party.
Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).
dateTime Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: ./time[type="TS" and isNormalDatatype()]
- cda: .authenticator.time
|
| party | I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idComposition.attester.party Who attested the composition Definition Who attested the composition in the specified way.
Identifies who has taken on the responsibility for accuracy of the composition content.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- w5: FiveWs.witness
- rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
- cda: .authenticator.assignedEnttty
|
| custodian | Σ I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idShort description Organization which maintains the composition Definition Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.
Identifies where to go to find the current version, where to report issues, etc.
This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.
Reference(Organization) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
- cda: .custodian.assignedCustodian
- fhirdocumentreference: DocumentReference.custodian
|
| relatesTo | | 0..* | BackboneElement | There are no (further) constraints on this element Element idShort description Relationships to other compositions/documents Definition Relationships that this composition has with other compositions or documents that already exist.
A document is a version specific composition.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: .outboundRelationship
- cda: .relatedDocument
- fhirdocumentreference: DocumentReference.relatesTo
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.relatesTo.extension Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.relatesTo.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| code | | 1..1 | codeBinding | There are no (further) constraints on this element Element idComposition.relatesTo.code replaces | transforms | signs | appends Definition The type of relationship that this composition has with anther composition or document.
If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.
code Binding The type of relationship between documents.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: .outboundRelationship.typeCode
- cda: .relatedDocument.typeCode
- fhirdocumentreference: DocumentReference.relatesTo.code
|
| target[x] | | 1..1 | | There are no (further) constraints on this element Element idComposition.relatesTo.target[x] Target of the relationship Definition The target composition/document of this relationship.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: .target[classCode="DOC", moodCode="EVN"].id
- cda: .relatedDocument.id
- fhirdocumentreference: DocumentReference.relatesTo.target
|
| targetIdentifier | | | Identifier | There are no (further) constraints on this element Data type Identifier |
| targetReference | | | Reference(Composition) | There are no (further) constraints on this element Data type Reference(Composition) |
| event | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idShort description The clinical service(s) being documented Definition The clinical service, such as a colonoscopy or an appendectomy, being documented.
Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.
The event needs to be consistent with the type element, though can provide further information if desired.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
- cda: .documentationOf.serviceEvent
- fhirdocumentreference: DocumentReference.event
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.event.extension Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.event.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| code | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idShort description Code(s) that apply to the event being documented Definition This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.
An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries.
CodeableConcept Binding This list of codes represents the main clinical acts being documented.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- rim: .code
- cda: .code
- fhirdocumentreference: DocumentReference.event.code
|
| period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idShort description The period covered by the documentation Definition The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.
A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times").
Period is not used for a duration (a measure of elapsed time). See Duration.
Period Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - per-1: If present, start SHALL have a lower value than end
start.hasValue().not() or end.hasValue().not() or (start <= end)
- rim: n/a
- v2: DR
- rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
- rim: .effectiveTime
- cda: .effectiveTime
- fhirdocumentreference: DocumentReference.event.period
|
| detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idShort description The event(s) being documented Definition The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Resource) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim: .outboundRelationship[typeCode="SUBJ"].target
- cda: n/a
|
| section | S I | 1..* | BackboneElement | Element idShort description Composition is broken into sections Definition The root of the sections that make up the composition.
BackboneElement Sliced: Unordered, Open, by Composition.section.entry().resolve()(Profile) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists() - cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()
- rim: n/a
- rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
- cda: .component.structuredBody.component.section
|
| (All Slices) | | | | There are no (further) constraints on this element |
| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section.extension Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| title | S | 0..1 | string | There are no (further) constraints on this element Element idComposition.section.title Label for section (e.g. for ToC) Alternate names header, label, caption Definition The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: ./title
- cda: .title
|
| code | S | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idShort description Classification of section (recommended) Definition A code identifying the kind of content contained within the section. This must be consistent with the section title.
Provides computable standardized labels to topics within the document.
The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.
If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
CodeableConcept Binding Classification of a section of a composition/document.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- rim: ./code
- cda: .code
|
| author | S I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section.author Who and/or what authored the section Definition Identifies who is responsible for the information in this section, not necessarily who typed it in.
Identifies who is responsible for the content.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- w5: FiveWs.author
- rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
- cda: .author.assignedAuthor
|
| focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section.focus Who/what the section is about, when it is not about the subject of composition Definition The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Reference(Resource) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- cda: .subject? (CDA did not differentiate between subject and focus)
|
| text | S I | 0..1 | Narrative | There are no (further) constraints on this element Element idShort description Text summary of the section, for human interpretation Definition A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Narrative Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: N/A
- rim: .text
- cda: .text
|
| mode | | 0..1 | codeBinding | There are no (further) constraints on this element Element idShort description working | snapshot | changes Definition How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
code Binding The processing mode that applies to this section.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- w5: FiveWs.class
- rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
- cda: n/a
|
| orderedBy | | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section.orderedBy Order of section entries Definition Specifies the order applied to the items in the section entries.
Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
CodeableConcept Binding What order applies to the items in the entry.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
- cda: n/a
|
| entry | S I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section.entry A reference to data that supports this section Definition A reference to the actual resource from which the narrative in the section is derived.
If there are no entries in the list, an emptyReason SHOULD be provided.
Reference(Resource) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
- cda: .entry
|
| emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section.emptyReason Why the section is empty Definition If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Allows capturing things like "none exist" or "not asked" which can be important for most lists.
The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
CodeableConcept Binding If a section is empty, why it is empty.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
- cda: n/a
|
| section | S I | 0..* | see (section) | There are no (further) constraints on this element Element idComposition.section.section Nested Section Definition A nested sub-section within this section.
Nested sections are primarily used to help human readers navigate to particular portions of the document.
- rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
- cda: .component.section
|
| diagRep | I | 1..1 | BackboneElement | There are no (further) constraints on this element Element idComposition.section:diagRep Composition is broken into sections Definition The root of the sections that make up the composition.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists() - cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()
- rim: n/a
- rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
- cda: .component.structuredBody.component.section
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:diagRep.id Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section:diagRep.extension Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section:diagRep.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
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| title | S | 0..1 | string | There are no (further) constraints on this element Element idComposition.section:diagRep.title Label for section (e.g. for ToC) Alternate names header, label, caption Definition The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: ./title
- cda: .title
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| code | S | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idComposition.section:diagRep.code Classification of section (recommended) Definition A code identifying the kind of content contained within the section. This must be consistent with the section title.
Provides computable standardized labels to topics within the document.
The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.
If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
CodeableConcept Binding Classification of a section of a composition/document.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- rim: ./code
- cda: .code
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| author | S I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section:diagRep.author Who and/or what authored the section Definition Identifies who is responsible for the information in this section, not necessarily who typed it in.
Identifies who is responsible for the content.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- w5: FiveWs.author
- rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
- cda: .author.assignedAuthor
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| focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section:diagRep.focus Who/what the section is about, when it is not about the subject of composition Definition The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Reference(Resource) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- cda: .subject? (CDA did not differentiate between subject and focus)
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| text | S I | 0..1 | Narrative | There are no (further) constraints on this element Element idComposition.section:diagRep.text Text summary of the section, for human interpretation Definition A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Narrative Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: N/A
- rim: .text
- cda: .text
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| mode | | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section:diagRep.mode working | snapshot | changes Definition How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
code Binding The processing mode that applies to this section.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- w5: FiveWs.class
- rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
- cda: n/a
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| orderedBy | | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:diagRep.orderedBy Order of section entries Definition Specifies the order applied to the items in the section entries.
Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
CodeableConcept Binding What order applies to the items in the entry.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
- cda: n/a
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| entry | S I | 0..* | Reference(MII_PR_Bildgebung_Radiologischer_Befund) | Element idComposition.section:diagRep.entry A reference to data that supports this section Definition A reference to the actual resource from which the narrative in the section is derived.
If there are no entries in the list, an emptyReason SHOULD be provided.
Reference(MII_PR_Bildgebung_Radiologischer_Befund) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
- cda: .entry
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| emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section:diagRep.emptyReason Why the section is empty Definition If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Allows capturing things like "none exist" or "not asked" which can be important for most lists.
The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
CodeableConcept Binding If a section is empty, why it is empty.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
- cda: n/a
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| section | S I | 0..* | see (section) | There are no (further) constraints on this element Element idComposition.section:diagRep.section Nested Section Definition A nested sub-section within this section.
Nested sections are primarily used to help human readers navigate to particular portions of the document.
- rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
- cda: .component.section
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