description: The Clinical Artifact represents the outpatient visit consultation note which may include clinical information on any OP examinations, procedures along with medication administered, and advice that can be shared across the health ecosystem.
package_name: ndhm.in
derivation: constraint
name: OPConsultRecord
type: Composition
elements:
  date: {mustSupport: true, index: 10}
  encounter:
    type: Reference
    mustSupport: true
    refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Encounter']
    index: 9
  section:
    mustSupport: true
    index: 17
    slicing:
      rules: openAtEnd
      discriminator:
      - {path: code.coding.code, type: value}
      min: 1
      slices:
        MedicalHistory:
          match:
            code:
              coding: {code: '371529009'}
          schema:
            short: The section records  patient’s past medical history, including previous diagnoses and treatments.
            index: 45
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 46
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 47
                      code:
                        pattern: {type: code, value: '371529009'}
                        type: code
                        index: 48
                      display:
                        pattern: {type: string, value: History and physical report}
                        type: string
                        index: 49
                    required: [code, display, system]
                  text: {mustSupport: true, index: 50}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 51
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Procedure']
                index: 52
                elements:
                  reference: {index: 53}
                required: [reference]
        DocumentReference:
          match:
            code:
              coding: {code: '371530004'}
          schema:
            short: The section records documents, such as PDFs or images, relevant to the consultation.
            index: 117
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 118
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 119
                      code:
                        pattern: {type: code, value: '371530004'}
                        type: code
                        index: 120
                      display:
                        pattern: {type: string, value: Clinical consultation report}
                        type: string
                        index: 121
                    required: [code, display, system]
                  text: {mustSupport: true, index: 122}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 123
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/DocumentReference']
                index: 124
                elements:
                  reference: {index: 125}
                required: [reference]
        OtherObservations:
          match:
            code:
              coding: {code: '404684003'}
          schema:
            short: The section records additional observations that do not fit into other sections.
            index: 108
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 109
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 110
                      code:
                        pattern: {type: code, value: '404684003'}
                        type: code
                        index: 111
                      display:
                        pattern: {type: string, value: Clinical finding}
                        type: string
                        index: 112
                    required: [code, display, system]
                  text: {mustSupport: true, index: 113}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 114
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Observation']
                index: 115
                elements:
                  reference: {index: 116}
                required: [reference]
        Allergies:
          match:
            code:
              coding: {code: '722446000'}
          schema:
            short: The section records  any known allergies patient has, including medication, food, or environmental triggers
            index: 36
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 37
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 38
                      code:
                        pattern: {type: code, value: '722446000'}
                        type: code
                        index: 39
                      display:
                        pattern: {type: string, value: Allergy record}
                        type: string
                        index: 40
                    required: [code, display, system]
                  text: {mustSupport: true, index: 41}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 42
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/AllergyIntolerance']
                index: 43
                elements:
                  reference: {index: 44}
                required: [reference]
        FollowUp:
          match:
            code:
              coding: {code: '390906007'}
          schema:
            short: The section records instructions for follow-up consultations or care.
            index: 81
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 82
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 83
                      code:
                        pattern: {type: code, value: '390906007'}
                        type: code
                        index: 84
                      display:
                        pattern: {type: string, value: Follow-up encounter}
                        type: string
                        index: 85
                    required: [code, display, system]
                  text: {mustSupport: true, index: 86}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 87
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Appointment']
                index: 88
                elements:
                  reference: {index: 89}
                required: [reference]
        ChiefComplaints:
          match:
            code:
              coding: {code: '422843007'}
          schema:
            index: 18
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 19
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 20
                      code:
                        pattern: {type: code, value: '422843007'}
                        type: code
                        index: 21
                      display:
                        pattern: {type: string, value: Chief complaint section}
                        type: string
                        index: 22
                    required: [code, display, system]
                  text: {mustSupport: true, index: 23}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 24
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Condition']
                index: 25
                elements:
                  reference: {index: 26}
                required: [reference]
        PhysicalExamination:
          match:
            code:
              coding: {code: '425044008'}
          schema:
            short: The section records the patient's  body's basic functions such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area etc.
            index: 27
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 28
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 29
                      code:
                        pattern: {type: code, value: '425044008'}
                        type: code
                        index: 30
                      display:
                        pattern: {type: string, value: Physical exam section}
                        type: string
                        index: 31
                    required: [code, display, system]
                  text: {mustSupport: true, index: 32}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 33
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Observation']
                index: 34
                elements:
                  reference: {index: 35}
                required: [reference]
        Medications:
          match:
            code:
              coding: {code: '721912009'}
          schema:
            short: The section records any medications prescribed or currently taken by the patient.
            index: 72
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 73
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 74
                      code:
                        pattern: {type: code, value: '721912009'}
                        type: code
                        index: 75
                      display:
                        pattern: {type: string, value: Medication summary document}
                        type: string
                        index: 76
                    required: [code, display, system]
                  text: {mustSupport: true, index: 77}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 78
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/MedicationRequest', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/MedicationStatement']
                index: 79
                elements:
                  reference: {index: 80}
                required: [reference]
        FamilyHistory:
          match:
            code:
              coding: {code: '422432008'}
          schema:
            short: The section records patient's relevant family medical history that may impact the patient’s health such as Diabetes etc.
            index: 54
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 55
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 56
                      code:
                        pattern: {type: code, value: '422432008'}
                        type: code
                        index: 57
                      display:
                        pattern: {type: string, value: Family history section}
                        type: string
                        index: 58
                    required: [code, display, system]
                  text: {mustSupport: true, index: 59}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 60
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/FamilyMemberHistory']
                index: 61
                elements:
                  reference: {index: 62}
                required: [reference]
        Procedure:
          match:
            code:
              coding: {code: '371525003'}
          schema:
            short: The section records any procedures performed.
            index: 90
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 91
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 92
                      code:
                        pattern: {type: code, value: '371525003'}
                        type: code
                        index: 93
                      display:
                        pattern: {type: string, value: Clinical procedure report}
                        type: string
                        index: 94
                    required: [code, display, system]
                  text: {mustSupport: true, index: 95}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 96
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Procedure']
                index: 97
                elements:
                  reference: {index: 98}
                required: [reference]
        InvestigationAdvice:
          match:
            code:
              coding: {code: '721963009'}
          schema:
            short: The section records information about recommended diagnostic tests or services.
            index: 63
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 64
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 65
                      code:
                        pattern: {type: code, value: '721963009'}
                        type: code
                        index: 66
                      display:
                        pattern: {type: string, value: Order document}
                        type: string
                        index: 67
                    required: [code, display, system]
                  text: {mustSupport: true, index: 68}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 69
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/ServiceRequest']
                index: 70
                elements:
                  reference: {index: 71}
                required: [reference]
        Referral:
          match:
            code:
              coding: {code: '306206005'}
          schema:
            short: The section records  information about any referrals made to other healthcare providers or specialists.
            index: 99
            elements:
              code:
                elements:
                  coding:
                    mustSupport: true
                    index: 100
                    elements:
                      system:
                        pattern: {type: uri, value: 'http://snomed.info/sct'}
                        type: uri
                        index: 101
                      code:
                        pattern: {type: code, value: '306206005'}
                        type: code
                        index: 102
                      display:
                        pattern: {type: string, value: Referral to service}
                        type: string
                        index: 103
                    required: [code, display, system]
                  text: {mustSupport: true, index: 104}
              author:
                type: Reference
                refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
                index: 105
              entry:
                type: Reference
                mustSupport: true
                refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/ServiceRequest']
                index: 106
                elements:
                  reference: {index: 107}
                required: [reference]
  attester:
    mustSupport: true
    index: 14
    elements:
      party:
        type: Reference
        refers: ['http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
        index: 15
  type:
    short: Kind of composition (SNOMED CT if possible)
    mustSupport: true
    index: 1
    elements:
      coding:
        index: 2
        elements:
          system:
            pattern: {type: uri, value: 'http://snomed.info/sct'}
            type: uri
            index: 3
          code:
            pattern: {type: code, value: '371530004'}
            type: code
            index: 4
          display:
            pattern: {type: string, value: Clinical consultation report}
            type: string
            index: 5
        required: [code, display, system]
      text: {mustSupport: true, index: 6}
    required: [coding]
  title: {mustSupport: true, index: 13}
  author:
    type: Reference
    mustSupport: true
    refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner', 'https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole']
    index: 11
    elements:
      reference: {index: 12}
    required: [reference]
  custodian:
    type: Reference
    refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization']
    index: 16
  status: {mustSupport: true, index: 0}
  subject:
    type: Reference
    mustSupport: true
    refers: ['https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient']
    index: 7
    elements:
      reference: {index: 8}
    required: [reference]
package_version: 6.5.0
class: profile
kind: resource
url: https://nrces.in/ndhm/fhir/r4/StructureDefinition/OPConsultRecord
base: http://hl7.org/fhir/StructureDefinition/Composition
version: 6.5.0
required: [encounter, section, subject]