{
"description": "This profile represents the constraints applied to the Composition resource by the PS-CA project.\\r\\nA Canadian Patient Summary (PS-CA) document is an electronic health record extract containing essential healthcare information about a subject of care. It is informed by the IPS-UV Composition profile, but differs in its application of Must Support flags on some of the sections to allow for jurisdictional implementors flexibility in what sections systems Must Support in order to show conformance to their respective patient summaries.\\r\\nThe PS-CA dataset is minimal and non-exhaustive; specialty-agnostic and condition-independent; but still clinically relevant. Its informed by the requirements specified in EN 17269 and ISO/DIS 27269, it is designed for supporting the international use case scenario for ‘unplanned, cross border care’, but is also designed to support a variety of use cases for cross-jurisdiction exchange. It is intended to guide implementation nationally while ensuring international exchange of patient summaries is not impeded.\\r\\n\\r\\nThis profile is based on the ClinicalDocument profile from the base R4 FHIR standard.",
"_filename": "structuredefinition-profile-composition-ca-ps.json",
"package_name": "ca.infoway.io.psca",
"date": "2023-12-21T00:00:00-08:00",
"derivation": "constraint",
"publisher": null,
"fhirVersion": "4.0.1",
"name": "CompositionPSCA",
"abstract": false,
"copyright": "Copyright © 2024+ Canada Health Infoway. All rights reserved. [Terms of Use and License Agreements](https://ic.infoway-inforoute.ca/en/about/tou). [Privacy Policy](https://www.infoway-inforoute.ca/en/legal/privacy-policy).",
"type": "Composition",
"experimental": "false",
"resourceType": "StructureDefinition",
"title": "Composition (PS-CA)",
"package_version": "2.0.0-DFT-Ballot-alpha-1",
"status": "draft",
"id": "76433cc3-7941-4dfd-a4f1-855d17900ced",
"kind": "resource",
"url": "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/composition-ca-ps",
"version": null,
"differential": {
"element": [ {
"id": "Composition",
"path": "Composition",
"short": "Canadian Patient Summary composition",
"definition": "Canadian Patient Summary composition.\r\nA composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement.\r\nWhile a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained."
}, {
"id": "Composition.text",
"path": "Composition.text",
"mustSupport": true
}, {
"id": "Composition.identifier",
"path": "Composition.identifier",
"mustSupport": true
}, {
"id": "Composition.status",
"path": "Composition.status",
"mustSupport": true
}, {
"id": "Composition.type",
"min": 1,
"path": "Composition.type",
"short": "Kind of composition (\"Patient Summary\")",
"definition": "Specifies that this composition refers to a Patient Summary (Loinc \"60591-5\")",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "60591-5",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.subject",
"min": 1,
"path": "Composition.subject",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/patient-ca-ps" ]
} ],
"definition": "Who or what the composition is about.\r\nIn general a 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).\r\nFor the PS the subject is always the patient.",
"mustSupport": true
}, {
"id": "Composition.subject.reference",
"min": 1,
"path": "Composition.subject.reference",
"mustSupport": true
}, {
"id": "Composition.encounter",
"path": "Composition.encounter",
"comment": "While IPS-UV considers this a Must Support element, policy has not yet been developed in Canada confirming the expectations for when a patient summary is created (e.g., does it have to be created by a health professional or just validated, can it be automatically assembled, does it have to occur within an encounter, etc.). This relaxation does not exclude or prevent implementers from further defining how encounter is used in their implementation if their use case(s) rely on its presence."
}, {
"id": "Composition.date",
"path": "Composition.date",
"mustSupport": true
}, {
"id": "Composition.author",
"path": "Composition.author",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-practitioner", "http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-practitionerrole", "http://hl7.org/fhir/StructureDefinition/Device", "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/patient-ca-ps", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-organization" ]
} ],
"short": "Who and/or what authored the patient summary",
"definition": "Identifies who is responsible for the information in the patient summary, not necessarily who typed it in.\r\n\r\nThe type of author(s) contribute to determine the \"nature\"of the Patient Summary: e.g., a \"human-curated\" PS Vs. an \"automatically generated\" PS.",
"mustSupport": true
}, {
"id": "Composition.title",
"path": "Composition.title",
"short": "CA Patient Summary",
"definition": "Official human-readable label for the composition.\n\nFor this document should be \"CA Patient Summary\" or any equivalent translation",
"mustSupport": true
}, {
"id": "Composition.confidentiality",
"path": "Composition.confidentiality"
}, {
"id": "Composition.attester",
"path": "Composition.attester",
"comment": "IPS-UV flags this as a Must Support element. It is not currently flagged as Must Support in PS-CA, as stakeholders have indicated the element may not be supported across workflows of Canadian jurisdictional implementers. \n\n These challenges have been raised in IPS. Further assessment of jurisdictional use cases need to be explored by the Patient Summary Working Group before the constraint will be re-considered for inclusion"
}, {
"id": "Composition.attester.mode",
"path": "Composition.attester.mode",
"comment": "While Composition.attester is not currently flagged as Must Support in PS-CA, Implementers who support attester are expected to support attester.mode, attester.time, and attester.party",
"mustSupport": true
}, {
"id": "Composition.attester.time",
"path": "Composition.attester.time",
"comment": "While Composition.attester is not currently flagged as Must Support in PS-CA, Implementers who support attester are expected to support attester.mode, attester.time, and attester.party",
"mustSupport": true
}, {
"id": "Composition.attester.party",
"path": "Composition.attester.party",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/patient-ca-ps", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-practitioner", "http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-practitionerrole", "http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-organization" ]
} ],
"comment": "While Composition.attester is not currently flagged as Must Support in PS-CA, Implementers who support attester are expected to support attester.mode, attester.time, and attester.party",
"mustSupport": true
}, {
"id": "Composition.custodian",
"path": "Composition.custodian",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-organization" ]
} ],
"mustSupport": true
}, {
"id": "Composition.relatesTo",
"path": "Composition.relatesTo"
}, {
"id": "Composition.relatesTo.code",
"path": "Composition.relatesTo.code"
}, {
"id": "Composition.relatesTo.target[x]",
"path": "Composition.relatesTo.target[x]",
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Composition", "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/composition-ca-ps" ]
} ]
}, {
"id": "Composition.event",
"path": "Composition.event",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "code",
"type": "pattern"
} ]
},
"definition": "IPS Note: The main activity being described by a PS is the provision of healthcare over a period of time. In the CDA representation of the PS this is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. In the FHIR representation at least one event should be used to record this information. Additional data from outside this duration may also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). For example if the PS is generated by a GP based on information recorded in his/her EHR-S, then the start value should represent the date when the treatment relationship between the patient and the GP started; and the end value the date of the latest care event."
}, {
"id": "Composition.event:careProvisioningEvent",
"max": "1",
"path": "Composition.event",
"short": "The care provisioning being documented",
"sliceName": "careProvisioningEvent",
"definition": "The provision of healthcare over a period of time this PS is documented."
}, {
"id": "Composition.event:careProvisioningEvent.code",
"min": 1,
"path": "Composition.event.code",
"comment": "While Composition.event:careProvisioningEvent slice is not currently flagged as Must Support in PS-CA, Implementers who support the slice are expected to support Composition.event:careProvisioningEvent.code and Composition.event:careProvisioningEvent.period",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "PCPR",
"system": "http://terminology.hl7.org/CodeSystem/v3-ActClass"
} ]
}
}, {
"id": "Composition.event:careProvisioningEvent.period",
"path": "Composition.event.period",
"comment": "While Composition.event:careProvisioningEvent slice is not currently flagged as Must Support in PS-CA, Implementers who support the slice are expected to support Composition.event:careProvisioningEvent.code and Composition.event:careProvisioningEvent.period",
"mustSupport": true
}, {
"id": "Composition.section",
"min": 1,
"path": "Composition.section",
"short": "Sections composing the PS",
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "code",
"type": "pattern"
} ]
},
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"definition": "The root of the sections that make up the PS-CA composition.",
"mustSupport": true
}, {
"id": "Composition.section.extension",
"path": "Composition.section.extension",
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "url",
"type": "value"
} ]
}
}, {
"id": "Composition.section.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/CodeableConcept-ca-ps" ]
} ],
"mustSupport": true
}, {
"id": "Composition.section.text",
"min": 1,
"path": "Composition.section.text",
"mustSupport": true
}, {
"id": "Composition.section.emptyReason",
"path": "Composition.section.emptyReason"
}, {
"constraint": [ {
"key": "ips-comp-1",
"human": "Either section.entry or emptyReason are present",
"xpath": "(/f:entry.reference and not /f:emptyReason) or (not(/f:emptyReason) and /f:entry.reference)",
"severity": "error",
"expression": "(entry.reference.exists() or emptyReason.exists())"
} ],
"path": "Composition.section",
"min": 1,
"definition": "The medication summary section contains a description of the patient's medications relevant for the scope of the patient summary. The actual content could depend on the jurisdiction, it could report:\r\n- the currently active medications;\r\n- the current and past medications considered relevant by the authoring GP;\r\n- the patient prescriptions or dispensations automatically extracted by a regional or a national EHR.\r\n\r\nBecause This section has been expanded in the PS-CA to model a medicationRequest profile in addition to medicationStatement profile initially included in IPS-UV.",
"short": "PS-CA Medication Summary Section",
"mustSupport": true,
"sliceName": "sectionMedications",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"max": "1",
"id": "Composition.section:sectionMedications",
"comment": "IPS-UV requires a minimum cardinality of 1 on this section to ensure it is always populated with some kind of data - though has recently updated to allow for the provision of section.emptyReason. This constraint has been maintained in the PS-CA. Systems should utilize the section.entry with a resource when conveying that the subject has no known medications (e.g., clinical assertions that are captured alongside supportive data like date). The section.emptyReason is available to convey details for why the section entry is empty (e.g., data unavailable)."
}, {
"id": "Composition.section:sectionMedications.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionMedications.title",
"min": 1,
"path": "Composition.section.title",
"short": "Medication Summary section",
"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.\r\n\r\nMedication Summary",
"mustSupport": true
}, {
"id": "Composition.section:sectionMedications.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "10160-0",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionMedications.entry",
"path": "Composition.section.entry",
"short": "Medications relevant for the scope of the patient summary",
"comment": "This entry requires a medicationStatement or a medicationRequest.",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "This list the medications relevant for the scope of the patient summary or it is used to indicate that the subject is known not to be on any relevant medication",
"mustSupport": true
}, {
"id": "Composition.section:sectionMedications.entry:medicationStatement",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/medicationstatement-ca-ps" ]
} ],
"short": "A reference to data that supports this section",
"sliceName": "medicationStatement",
"definition": "A reference to the actual resource from which the narrative in the section is derived."
}, {
"id": "Composition.section:sectionMedications.entry:medicationRequest",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/medicationrequest-ca-ps" ]
} ],
"short": "A reference to data that supports this section",
"sliceName": "medicationRequest",
"definition": "A reference to the actual resource from which the narrative in the section is derived."
}, {
"id": "Composition.section:sectionMedications.section",
"max": "0",
"path": "Composition.section.section"
}, {
"constraint": [ {
"key": "ips-comp-1",
"human": "Either section.entry or emptyReason are present",
"xpath": "(/f:entry.reference and not /f:emptyReason) or (not(/f:emptyReason) and /f:entry.reference)",
"severity": "error",
"expression": "(entry.reference.exists() or emptyReason.exists())"
} ],
"path": "Composition.section",
"min": 1,
"definition": "This section documents the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g., rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy.\r\nAt a minimum, it should list currently active and any relevant historical allergies and adverse reactions.\r\nIf no information about allergies is available, or if no allergies are known this should be clearly documented in the section.",
"short": "PS-CA Allergies and Intolerances Section",
"mustSupport": true,
"sliceName": "sectionAllergies",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"max": "1",
"id": "Composition.section:sectionAllergies",
"comment": "IPS-UV requires a minimum cardinality of 1 on this section to ensure it is always populated with some kind of data - though has recently updated to allow for the provision of section.emptyReason. This constraint has been maintained in the PS-CA. Systems should utilize the section.entry with a resource when conveying that the subject has no known allergies (e.g., clinical assertions that are captured alongside supportive data like date). The section.emptyReason is available to convey details for why the section entry is empty (e.g., data unavailable)."
}, {
"id": "Composition.section:sectionAllergies.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionAllergies.title",
"min": 1,
"path": "Composition.section.title",
"short": "Allergies and Intolerances",
"mustSupport": true
}, {
"id": "Composition.section:sectionAllergies.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "48765-2",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionAllergies.entry",
"path": "Composition.section.entry",
"short": "Relevant allergies or intolerances (conditions) for that patient.",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "It lists the relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g., rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy.\r\nAt a minimum, it should list currently active and any relevant historical allergies and adverse reactions.",
"mustSupport": true
}, {
"id": "Composition.section:sectionAllergies.entry:allergyOrIntolerance",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/allergyintolerance-ca-ps" ]
} ],
"short": "A reference to data that supports this section",
"sliceName": "allergyOrIntolerance",
"definition": "A reference to the actual resource from which the narrative in the section is derived."
}, {
"id": "Composition.section:sectionAllergies.section",
"max": "0",
"path": "Composition.section.section"
}, {
"constraint": [ {
"key": "ips-comp-1",
"human": "Either section.entry or emptyReason are present",
"xpath": "(/f:entry.reference and not /f:emptyReason) or (not(/f:emptyReason) and /f:entry.reference)",
"severity": "error",
"expression": "(entry.reference.exists() or emptyReason.exists())"
} ],
"path": "Composition.section",
"min": 1,
"definition": "The PS problem section lists and describes clinical problems or conditions currently being monitored for the patient.",
"short": "PS-CA Problems Section",
"mustSupport": true,
"sliceName": "sectionProblems",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"max": "1",
"id": "Composition.section:sectionProblems",
"comment": "IPS-UV requires a minimum cardinality of 1 on this section to ensure it is always populated with some kind of data - though has recently updated to allow for the provision of section.emptyReason. This constraint has been maintained in the PS-CA. Systems should utilize the section.entry with a resource when conveying that the subject has no known conditions (e.g., clinical assertions that are captured alongside supportive data like date). The section.emptyReason is available to convey details for why the section entry is empty (e.g., data unavailable)."
}, {
"id": "Composition.section:sectionProblems.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionProblems.title",
"min": 1,
"path": "Composition.section.title",
"mustSupport": true
}, {
"id": "Composition.section:sectionProblems.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "11450-4",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionProblems.entry",
"path": "Composition.section.entry",
"short": "Clinical problems or conditions currently being monitored for the patient.",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "It lists and describes clinical problems or conditions currently being monitored for the patient.",
"mustSupport": true
}, {
"id": "Composition.section:sectionProblems.entry:problem",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/condition-ca-ps" ]
} ],
"short": "A reference to data that supports this section",
"sliceName": "problem",
"definition": "A reference to the actual resource from which the narrative in the section is derived."
}, {
"id": "Composition.section:sectionProblems.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionProceduresHx",
"max": "1",
"path": "Composition.section",
"short": "PS-CA History of Procedures Section",
"comment": "IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error. Additionally vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"sliceName": "sectionProceduresHx",
"definition": "The History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document.\r\nProcedures may refer for example to:\r\n1. Invasive Diagnostic procedure: e.g., Cardiac catheterization; (the results of these procedure are documented in the results section)\r\n2. Therapeutic procedure: e.g., dialysis;\r\n3. Surgical procedure: e.g., appendectomy"
}, {
"id": "Composition.section:sectionProceduresHx.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionProceduresHx.title",
"min": 1,
"path": "Composition.section.title",
"mustSupport": true
}, {
"id": "Composition.section:sectionProceduresHx.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "47519-4",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionProceduresHx.entry",
"path": "Composition.section.entry",
"short": "Patient past procedures pertinent to the scope of this document.",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "It lists the patient past procedures that are pertinent to the scope of this document.\r\nProcedures may refer for example to:\r\n1. Invasive Diagnostic procedure: e.g., Cardiac catheterization; (the results of these procedure are documented in the results section)\r\n2. Therapeutic procedure: e.g., dialysis;\r\n3. Surgical procedure: e.g., appendectomy.",
"mustSupport": true
}, {
"id": "Composition.section:sectionProceduresHx.entry:procedure",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/procedure-ca-ps" ]
} ],
"sliceName": "procedure",
"mustSupport": true
}, {
"id": "Composition.section:sectionProceduresHx.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionImmunizations",
"max": "1",
"path": "Composition.section",
"short": "PS-CA Immunizations Section",
"comment": "IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error. Additionally vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"sliceName": "sectionImmunizations",
"definition": "The Immunizations Section defines a patient's current immunization status and pertinent immunization history.\r\nThe primary use case for the Immunization Section is to enable communication of a patient's immunization status.\r\nThe section includes the current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized."
}, {
"id": "Composition.section:sectionImmunizations.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionImmunizations.title",
"min": 1,
"path": "Composition.section.title",
"mustSupport": true
}, {
"id": "Composition.section:sectionImmunizations.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "11369-6",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionImmunizations.entry",
"path": "Composition.section.entry",
"short": "Patient's immunization status and pertinent history.",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "It defines the patient's current immunization status and pertinent immunization history.\r\nThe primary use case for the Immunization Section is to enable communication of a patient's immunization status.\r\nIt may contain the entire immunization history that is relevant to the period of time being summarized.",
"mustSupport": true
}, {
"id": "Composition.section:sectionImmunizations.entry:immunization",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/immunization-ca-ps" ]
} ],
"sliceName": "immunization",
"mustSupport": true
}, {
"id": "Composition.section:sectionImmunizations.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionMedicalDevices",
"max": "1",
"path": "Composition.section",
"short": "PS-CA Medical Devices Section",
"comment": "IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries, future releases may further constrain this section as more jurisdictions look to support its use",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"sliceName": "sectionMedicalDevices",
"definition": "The medical devices section contains narrative text and coded entries describing the patient history of medical device use."
}, {
"id": "Composition.section:sectionMedicalDevices.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionMedicalDevices.title",
"min": 1,
"path": "Composition.section.title",
"mustSupport": true
}, {
"id": "Composition.section:sectionMedicalDevices.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "46264-8",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionMedicalDevices.entry",
"path": "Composition.section.entry",
"short": "Patient history of medical device use.",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "It describes the patient history of medical device use. This entry shall be used to document that no information about medical device use is available, or that no relevant medical device use is known.",
"mustSupport": true
}, {
"id": "Composition.section:sectionMedicalDevices.entry:deviceStatement",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/DeviceUseStatement-uv-ips" ]
} ],
"comment": "Pending definition of a PS CA device use section profile in a future release of PS CA, implementors are encouraged to use the IPS device use section profile.",
"sliceName": "deviceStatement",
"mustSupport": true
}, {
"id": "Composition.section:sectionMedicalDevices.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionResults",
"max": "1",
"path": "Composition.section",
"short": "PS-CA Results Section",
"comment": "IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error. Additionally vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Results Section"
} ],
"sliceName": "sectionResults",
"definition": "This section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results."
}, {
"id": "Composition.section:sectionResults.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionResults.title",
"min": 1,
"path": "Composition.section.title",
"mustSupport": true
}, {
"id": "Composition.section:sectionResults.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "30954-2",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionResults.entry",
"path": "Composition.section.entry",
"short": "Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, others, radiology results, and others, clinical results.",
"mustSupport": true
}, {
"id": "Composition.section:sectionResults.entry:results-observation-laboratory-pathology",
"max": "*",
"min": 0,
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/observation-results-laboratory-pathology-ca-ps" ]
} ],
"sliceName": "results-observation-laboratory-pathology",
"mustSupport": true
}, {
"id": "Composition.section:sectionResults.entry:results-observation-radiology",
"max": "*",
"min": 0,
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/observation-results-radiology-ca-ps" ]
} ],
"sliceName": "results-observation-radiology",
"mustSupport": true
}, {
"id": "Composition.section:sectionResults.entry:results-diagnosticReport",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/diagnosticreport-ca-ps" ]
} ],
"comment": "Pending definition of a PS CA diagnostic report profile in a future release of PS CA, implementors are encouraged to use the IPS diagnostic report profile.",
"sliceName": "results-diagnosticReport",
"mustSupport": true
}, {
"id": "Composition.section:sectionResults.section",
"max": "0",
"path": "Composition.section.section"
}, {
"path": "Composition.section",
"definition": "The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included",
"short": "PS-CA Vital Signs Section",
"sliceName": "sectionVitalSigns",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Vital Signs Section"
} ],
"max": "1",
"label": "Vital signs",
"id": "Composition.section:sectionVitalSigns",
"comment": "IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error. Additionally vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content"
}, {
"id": "Composition.section:sectionVitalSigns.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionVitalSigns.title",
"min": 1,
"path": "Composition.section.title",
"mustSupport": true
}, {
"id": "Composition.section:sectionVitalSigns.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "8716-3",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionVitalSigns.entry",
"path": "Composition.section.entry",
"short": "Notable vital signs or physical findings.",
"comment": "IPS-UV and PS-CA point to the parent vital signs profile (http://hl7.org/fhir/StructureDefinition/vitalsigns) in the base FHIR specification, it is up to the jurisdictions to select and support the individual vital sign profiles. However, to support implementers in validation - the individual vital signs profiles have been included as individual slices below. The parent vital signs profile has been removed as a slice to prevent examples from matching multiple slices.",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "Notable vital signs or physical findings as: blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included",
"mustSupport": true
}, {
"id": "Composition.section:sectionVitalSigns.entry:BMI",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/bmi" ]
} ],
"sliceName": "BMI"
}, {
"id": "Composition.section:sectionVitalSigns.entry:BP",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/bp" ]
} ],
"sliceName": "BP"
}, {
"id": "Composition.section:sectionVitalSigns.entry:BodyHeight",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/bodyheight" ]
} ],
"sliceName": "BodyHeight"
}, {
"id": "Composition.section:sectionVitalSigns.entry:BodyTemp",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/bodytemp" ]
} ],
"sliceName": "BodyTemp"
}, {
"id": "Composition.section:sectionVitalSigns.entry:BodyWeight",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/bodyweight" ]
} ],
"sliceName": "BodyWeight"
}, {
"id": "Composition.section:sectionVitalSigns.entry:HeadCircum",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/headcircum" ]
} ],
"sliceName": "HeadCircum"
}, {
"id": "Composition.section:sectionVitalSigns.entry:HeartRate",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/heartrate" ]
} ],
"sliceName": "HeartRate"
}, {
"id": "Composition.section:sectionVitalSigns.entry:OxygenSat",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/oxygensat" ]
} ],
"sliceName": "OxygenSat"
}, {
"id": "Composition.section:sectionVitalSigns.entry:RespRate",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/resprate" ]
} ],
"sliceName": "RespRate"
}, {
"id": "Composition.section:sectionVitalSigns.entry:VitalsPanel",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/vitalspanel" ]
} ],
"sliceName": "VitalsPanel"
}, {
"id": "Composition.section:sectionVitalSigns.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionPastIllnessHx",
"max": "1",
"path": "Composition.section",
"short": "PS-CA History of Past Illness Section",
"comment": "IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error. Additionally vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"sliceName": "sectionPastIllnessHx",
"definition": "The History of Past Illness section contains a description of the conditions the patient suffered in the past."
}, {
"id": "Composition.section:sectionPastIllnessHx.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionPastIllnessHx.title",
"min": 1,
"path": "Composition.section.title",
"mustSupport": true
}, {
"id": "Composition.section:sectionPastIllnessHx.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "11348-0",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionPastIllnessHx.entry",
"path": "Composition.section.entry",
"short": "Conditions the patient suffered in the past.",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "It contains a description of the conditions the patient suffered in the past.",
"mustSupport": true
}, {
"id": "Composition.section:sectionPastIllnessHx.entry:pastProblem",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/condition-ca-ps" ]
} ],
"sliceName": "pastProblem",
"mustSupport": true
}, {
"id": "Composition.section:sectionPastIllnessHx.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionFunctionalStatus",
"max": "1",
"path": "Composition.section",
"short": "PS-CA Functional Status",
"comment": "IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"sliceName": "sectionFunctionalStatus",
"definition": "The functional status section shall contain a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments.\r\nProfiles to express disabilities and functional assessments will be specified by future versions of this guide."
}, {
"id": "Composition.section:sectionFunctionalStatus.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionFunctionalStatus.title",
"min": 1,
"path": "Composition.section.title",
"mustSupport": true
}, {
"id": "Composition.section:sectionFunctionalStatus.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "47420-5",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionFunctionalStatus.entry",
"path": "Composition.section.entry",
"short": "Optional entry used to represent disabilities and functional assessments",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "It describes capabilities of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments.\r\nProfiles to express disabilities and functional assessments will be specified by future versions of this guide.",
"mustSupport": true
}, {
"id": "Composition.section:sectionFunctionalStatus.entry:disability",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/condition-ca-ps" ]
} ],
"sliceName": "disability",
"mustSupport": true
}, {
"id": "Composition.section:sectionFunctionalStatus.entry:functionalAssessment",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ClinicalImpression" ]
} ],
"sliceName": "functionalAssessment",
"mustSupport": true
}, {
"id": "Composition.section:sectionFunctionalStatus.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionPlanOfCare",
"max": "1",
"path": "Composition.section",
"short": "PS-CA Plan of Care Section",
"comment": "IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"sliceName": "sectionPlanOfCare",
"definition": "The plan of care section contains a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient."
}, {
"id": "Composition.section:sectionPlanOfCare.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionPlanOfCare.title",
"min": 1,
"path": "Composition.section.title",
"mustSupport": true
}, {
"id": "Composition.section:sectionPlanOfCare.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "18776-5",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionPlanOfCare.entry",
"path": "Composition.section.entry",
"short": "Optional entry used to represent structured care plans",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "Dynamic, personalized plan including identified needed healthcare activity, health objectives and healthcare goals, relating to one or more specified health issues in a healthcare process [Source EN ISO 13940]",
"mustSupport": true
}, {
"id": "Composition.section:sectionPlanOfCare.entry:carePlan",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/CarePlan" ]
} ],
"sliceName": "carePlan"
}, {
"id": "Composition.section:sectionPlanOfCare.entry:documentReference",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DocumentReference" ]
} ],
"sliceName": "documentReference"
}, {
"id": "Composition.section:sectionPlanOfCare.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionSocialHistory",
"max": "1",
"path": "Composition.section",
"short": "PS-CA Social History Section",
"comment": "IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error. Additionally vendors should expect that some jurisdictions may further constrain support of this section within the context of their own jurisdictional content",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"sliceName": "sectionSocialHistory",
"definition": "The social history section contains a description of the person’s Health related \"lifestyle factors\" or \"lifestyle observations\" (e.g., smoke habits; alcohol consumption; diets, risky habits.)"
}, {
"id": "Composition.section:sectionSocialHistory.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionSocialHistory.title",
"min": 1,
"path": "Composition.section.title",
"mustSupport": true
}, {
"id": "Composition.section:sectionSocialHistory.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "29762-2",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionSocialHistory.entry",
"path": "Composition.section.entry",
"short": "Health related \"lifestyle factors\" or \"lifestyle observations\" (e.g., smoke habits; alcohol consumption; diets, risky habits.)",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "Description of the person’s Health related “lifestyle factors\" or \"lifestyle observations\" (e.g., smoke habits; alcohol consumption; diets, risky habits.)",
"mustSupport": true
}, {
"id": "Composition.section:sectionSocialHistory.entry:generalSocialHistory",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/observation-socialhistory-ca-ps" ]
} ],
"sliceName": "generalSocialHistory"
}, {
"id": "Composition.section:sectionSocialHistory.entry:smokingTobaccoUse",
"max": "1",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/observation-tobaccouse-ca-ps" ]
} ],
"sliceName": "smokingTobaccoUse"
}, {
"id": "Composition.section:sectionSocialHistory.entry:alcoholUse",
"max": "1",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/observation-alcoholuse-ca-ps" ]
} ],
"sliceName": "alcoholUse"
}, {
"id": "Composition.section:sectionSocialHistory.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionPregnancyHx",
"max": "1",
"path": "Composition.section",
"short": "PS-CA History of Pregnancy Section",
"comment": "IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries. Participating jurisdictions are expected to be able to receive this section in a patient summary without flagging an error.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"sliceName": "sectionPregnancyHx",
"definition": "The history of pregnancy section shall contain information about whether the patient is currently pregnant or not.\r\nIt may contain addition summarizing information about the outcome of earlier pregnancies."
}, {
"id": "Composition.section:sectionPregnancyHx.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionPregnancyHx.title",
"min": 1,
"path": "Composition.section.title",
"mustSupport": true
}, {
"id": "Composition.section:sectionPregnancyHx.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "10162-6",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionPregnancyHx.entry",
"path": "Composition.section.entry",
"short": "Current pregnancy status and, optionally, information about the outcome of earlier pregnancies.",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "It contains information about whether the patient is currently pregnant or not.\r\nIt may contain addition summarizing information about the outcome of earlier pregnancies.",
"mustSupport": true
}, {
"id": "Composition.section:sectionPregnancyHx.entry:pregnancyStatus",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-pregnancy-status-uv-ips" ]
} ],
"comment": "Pending definition of a PS CA pregnancy status observation profile in a future release of PS CA, implementors are encouraged to use the IPS pregnancy status observation profile.",
"sliceName": "pregnancyStatus",
"mustSupport": true
}, {
"id": "Composition.section:sectionPregnancyHx.entry:pregnancyOutcomeSummary",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-pregnancy-outcome-uv-ips" ]
} ],
"comment": "Pending definition of a PS CA pregnancy outcome observation profile in a future release of PS CA, implementors are encouraged to use the IPS pregnancy outcome observation profile.",
"sliceName": "pregnancyOutcomeSummary",
"mustSupport": true
}, {
"id": "Composition.section:sectionPregnancyHx.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionAdvanceDirectives",
"max": "1",
"path": "Composition.section",
"short": "PS-CA Advance Directives Section",
"comment": "IPS-UV considers this a Must Support section. This constraint has been relaxed in the PS-CA to allow for jurisdictions who will not be including this domain/section in their initial implementation of patient summaries.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"sliceName": "sectionAdvanceDirectives",
"definition": "The advance directives section contains a narrative description of patient's advance directive."
}, {
"id": "Composition.section:sectionAdvanceDirectives.extension:section-note",
"max": "1",
"min": 0,
"path": "Composition.section.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/note" ]
} ],
"short": "Additional notes that apply to the section (but not to specific resource).",
"sliceName": "section-note",
"definition": "Additional notes that apply to the section (but not to specific resource)."
}, {
"id": "Composition.section:sectionAdvanceDirectives.title",
"min": 1,
"path": "Composition.section.title",
"mustSupport": true
}, {
"id": "Composition.section:sectionAdvanceDirectives.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "42348-3",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionAdvanceDirectives.entry",
"path": "Composition.section.entry",
"short": "Narrative description of the patient's advance directive.",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "Contains a narrative description or a Consent entry with information about the patient's advance directive.",
"mustSupport": true
}, {
"id": "Composition.section:sectionAdvanceDirectives.entry:advanceDirectivesConsent",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Consent" ]
} ],
"sliceName": "advanceDirectivesConsent"
}, {
"id": "Composition.section:sectionAdvanceDirectives.entry:advanceDirectivesDocumentReference",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DocumentReference" ]
} ],
"sliceName": "advanceDirectivesDocumentReference"
}, {
"id": "Composition.section:sectionAdvanceDirectives.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionFamilyHistory",
"max": "1",
"path": "Composition.section",
"short": "PS-CA Family History Section",
"comment": "This is a new section being introduced by the PS-CA specification at the request of jurisdictions.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Section"
} ],
"sliceName": "sectionFamilyHistory",
"definition": "The family history section contains a description of the patient's family history."
}, {
"id": "Composition.section:sectionFamilyHistory.title",
"min": 1,
"path": "Composition.section.title",
"mustSupport": true
}, {
"id": "Composition.section:sectionFamilyHistory.code",
"min": 1,
"path": "Composition.section.code",
"mustSupport": true,
"patternCodeableConcept": {
"coding": [ {
"code": "10157-6",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionFamilyHistory.entry",
"path": "Composition.section.entry",
"short": "Narrative description of the patient's family history.",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"mustSupport": true
}, {
"id": "Composition.section:sectionFamilyHistory.entry:FamilyMemberHistory",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/familymemberhistory-ca-ps" ]
} ],
"sliceName": "FamilyMemberHistory",
"mustSupport": true
}, {
"id": "Composition.section:sectionFamilyHistory.section",
"max": "0",
"path": "Composition.section.section"
} ]
},
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/Composition"
}