{
"description": "Clinical document used to represent a Hospital Discharge Report (HDR) for the scope of this guide.",
"_filename": "StructureDefinition-composition-eu-hdr.json",
"package_name": "hl7.fhir.eu.hdr",
"date": "2025-06-03T12:48:49+02:00",
"derivation": "constraint",
"publisher": "HL7 Europe",
"fhirVersion": "4.0.1",
"jurisdiction": [ {
"coding": [ {
"code": "150",
"system": "http://unstats.un.org/unsd/methods/m49/m49.htm",
"display": "Europe"
} ]
} ],
"name": "CompositionEuHdr",
"mapping": [ {
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern",
"identity": "workflow"
}, {
"uri": "http://hl7.org/v3",
"name": "RIM Mapping",
"identity": "rim"
}, {
"uri": "http://hl7.org/v3/cda",
"name": "CDA (R2)",
"identity": "cda"
}, {
"uri": "http://hl7.org/fhir/documentreference",
"name": "FHIR DocumentReference",
"identity": "fhirdocumentreference"
}, {
"uri": "http://hl7.org/fhir/fivews",
"name": "FiveWs Pattern Mapping",
"identity": "w5"
} ],
"abstract": false,
"copyright": "Used by permission of HL7 Europe, all rights reserved Creative Commons License",
"type": "Composition",
"experimental": null,
"resourceType": "StructureDefinition",
"title": "Composition (HDR)",
"package_version": "0.1.0-ballot",
"snapshot": {
"element": [ {
"constraint": [ {
"key": "dom-2",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"xpath": "not(parent::f:contained and f:contained)",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.contained.empty()"
}, {
"key": "dom-3",
"human": "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",
"xpath": "not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "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()"
}, {
"key": "dom-4",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()"
}, {
"key": "dom-5",
"human": "If a resource is contained in another resource, it SHALL NOT have a security label",
"xpath": "not(exists(f:contained/*/f:meta/f:security))",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.meta.security.empty()"
}, {
"key": "dom-6",
"human": "A resource should have narrative for robust management",
"xpath": "exists(f:text/h:div)",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "warning",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice",
"valueBoolean": true
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation",
"valueMarkdown": "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time."
} ],
"expression": "text.`div`.exists()"
}, {
"key": "text-or-section",
"human": "A Composition SHALL have either text, at least one section, or both.",
"source": "http://hl7.eu/fhir/hdr/StructureDefinition/composition-eu-hdr",
"severity": "error",
"expression": "text.exists() or section.exists()"
} ],
"path": "Composition",
"min": 0,
"definition": "Hospital Discharge Report 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.",
"isModifier": false,
"short": "Hospital Discharge Report composition",
"mapping": [ {
"map": "Entity. Role, or Act",
"identity": "rim"
}, {
"map": "Event",
"identity": "workflow"
}, {
"map": "Document[classCode=\"DOC\" and moodCode=\"EVN\" and isNormalAct()]",
"identity": "rim"
}, {
"map": "ClinicalDocument",
"identity": "cda"
}, {
"map": "when described by DocumentReference",
"identity": "fhirdocumentreference"
} ],
"max": "*",
"id": "Composition",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Composition"
},
"isSummary": false
}, {
"path": "Composition.id",
"min": 0,
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"isModifier": false,
"short": "Logical id of this artifact",
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "id"
} ]
} ],
"max": "1",
"id": "Composition.id",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.id"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.meta",
"min": 0,
"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.",
"isModifier": false,
"short": "Metadata about the resource",
"type": [ {
"code": "Meta"
} ],
"max": "1",
"id": "Composition.meta",
"base": {
"max": "1",
"min": 0,
"path": "Resource.meta"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.implicitRules",
"min": 0,
"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.",
"isModifier": true,
"short": "A set of rules under which this content was created",
"type": [ {
"code": "uri"
} ],
"max": "1",
"id": "Composition.implicitRules",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.implicitRules"
},
"isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.language",
"min": 0,
"definition": "The base language in which the resource is written.",
"isModifier": false,
"short": "Language of the resource content",
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/languages",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
} ],
"description": "A human language."
},
"max": "1",
"id": "Composition.language",
"comment": "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).",
"base": {
"max": "1",
"min": 0,
"path": "Resource.language"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the resource, for human interpretation",
"mapping": [ {
"map": "Act.text?",
"identity": "rim"
} ],
"type": [ {
"code": "Narrative"
} ],
"alias": [ "narrative", "html", "xhtml", "display" ],
"max": "1",
"id": "Composition.text",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "DomainResource.text"
},
"isSummary": false
}, {
"path": "Composition.contained",
"min": 0,
"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.",
"isModifier": false,
"short": "Contained, inline Resources",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Resource"
} ],
"alias": [ "inline resources", "anonymous resources", "contained resources" ],
"max": "*",
"id": "Composition.contained",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.contained"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.extension",
"min": 0,
"definition": "An Extension",
"isModifier": false,
"short": "Extension",
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"max": "*",
"id": "Composition.extension",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.extension",
"min": 0,
"definition": "A plan, proposal or order that is fulfilled in whole or in part by this event.",
"isModifier": false,
"short": "Fulfills plan, proposal or order",
"mapping": [ {
"map": "Event.basedOn",
"identity": "workflow"
}, {
"map": "ORC in proximity to EVN segment",
"identity": "v2"
}, {
"map": ".outboundRelationship[typeCode=FLFS].target",
"identity": "rim"
} ],
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/event-basedOn" ]
} ],
"sliceName": "basedOn",
"max": "*",
"id": "Composition.extension:basedOn",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
},
"isSummary": false
}, {
"path": "Composition.extension.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "id"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.extension:basedOn.id",
"condition": [ "ele-1" ],
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.extension.extension",
"min": 0,
"definition": "An Extension",
"isModifier": false,
"short": "Extension",
"slicing": {
"rules": "open",
"description": "Extensions are always sliced by (at least) url",
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"max": "0",
"id": "Composition.extension:basedOn.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "Composition.extension.url",
"min": 1,
"definition": "Source of the definition for the extension code - a logical name or a URL.",
"isModifier": false,
"short": "identifies the meaning of the extension",
"fixedUri": "http://hl7.org/fhir/StructureDefinition/event-basedOn",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "uri"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.extension:basedOn.url",
"comment": "The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.",
"base": {
"max": "1",
"min": 1,
"path": "Extension.url"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.extension.value[x]",
"min": 1,
"definition": "Value of extension - must be one of a constrained set of the data types (see [Extensibility](http://hl7.org/fhir/R5/extensibility.html) for a list).",
"isModifier": false,
"short": "Value of extension",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource", "http://hl7.org/fhir/StructureDefinition/ServiceRequest" ]
} ],
"max": "1",
"id": "Composition.extension:basedOn.value[x]",
"condition": [ "ext-1" ],
"base": {
"max": "1",
"min": 0,
"path": "Extension.value[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.extension",
"min": 0,
"definition": "Human readable representation of the entire document. Multiple formats are allowed but they SHALL be semantically equivalent.",
"isModifier": false,
"short": "Presented form",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.eu/fhir/StructureDefinition/presentedForm" ]
} ],
"sliceName": "presentedForm",
"max": "*",
"id": "Composition.extension:presentedForm",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
},
"isSummary": false
}, {
"path": "Composition.extension.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "id"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.extension:presentedForm.id",
"condition": [ "ele-1" ],
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.extension.extension",
"min": 0,
"definition": "An Extension",
"isModifier": false,
"short": "Extension",
"slicing": {
"rules": "open",
"description": "Extensions are always sliced by (at least) url",
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"max": "0",
"id": "Composition.extension:presentedForm.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "Composition.extension.url",
"min": 1,
"definition": "Source of the definition for the extension code - a logical name or a URL.",
"isModifier": false,
"short": "identifies the meaning of the extension",
"fixedUri": "http://hl7.eu/fhir/StructureDefinition/presentedForm",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "uri"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.extension:presentedForm.url",
"comment": "The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.",
"base": {
"max": "1",
"min": 1,
"path": "Extension.url"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.extension.value[x]",
"min": 0,
"definition": "Value of extension - must be one of a constrained set of the data types (see [Extensibility](http://hl7.org/fhir/R5/extensibility.html) for a list).",
"isModifier": false,
"short": "Value of extension",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Attachment"
} ],
"max": "1",
"id": "Composition.extension:presentedForm.value[x]",
"condition": [ "ext-1" ],
"base": {
"max": "1",
"min": 0,
"path": "Extension.value[x]"
},
"isSummary": false
}, {
"path": "Composition.extension.value[x].id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.extension:presentedForm.value[x].id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.extension.value[x].extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"slicing": {
"rules": "open",
"description": "Extensions are always sliced by (at least) url",
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.extension:presentedForm.value[x].extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.extension.value[x].contentType",
"requirements": "Processors of the data need to be able to know how to interpret the data.",
"min": 0,
"definition": "Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.",
"isModifier": false,
"short": "Mime type of the content, with charset etc.",
"mapping": [ {
"map": "ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used",
"identity": "v2"
}, {
"map": "./mediaType, ./charset",
"identity": "rim"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/mimetypes|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MimeType"
} ],
"description": "The mime type of an attachment. Any valid mime type is allowed."
},
"max": "1",
"id": "Composition.extension:presentedForm.value[x].contentType",
"example": [ {
"label": "General",
"valueCode": "text/plain; charset=UTF-8, image/png"
}, {
"label": "pdf",
"valueCode": "application/pdf"
} ],
"base": {
"max": "1",
"min": 0,
"path": "Attachment.contentType"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.extension.value[x].language",
"requirements": "Users need to be able to choose between the languages in a set of attachments.",
"min": 0,
"definition": "The human language of the content. The value can be any valid value according to BCP 47.",
"isModifier": false,
"short": "Human language of the content (BCP-47)",
"mapping": [ {
"map": "./language",
"identity": "rim"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/languages",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
} ],
"description": "A human language."
},
"max": "1",
"id": "Composition.extension:presentedForm.value[x].language",
"example": [ {
"label": "General",
"valueCode": "en-AU"
} ],
"base": {
"max": "1",
"min": 0,
"path": "Attachment.language"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.extension.value[x].data",
"requirements": "The data needs to able to be transmitted inline.",
"min": 0,
"definition": "The actual data of the attachment - a sequence of bytes, base64 encoded.",
"isModifier": false,
"short": "B64 in-line data",
"mapping": [ {
"map": "ED.5",
"identity": "v2"
}, {
"map": "./data",
"identity": "rim"
} ],
"type": [ {
"code": "base64Binary"
} ],
"max": "1",
"id": "Composition.extension:presentedForm.value[x].data",
"comment": "The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.",
"base": {
"max": "1",
"min": 0,
"path": "Attachment.data"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.extension.value[x].url",
"requirements": "The data needs to be transmitted by reference.",
"min": 0,
"definition": "A location where the data can be accessed.",
"isModifier": false,
"short": "URL of the document",
"mapping": [ {
"map": "RP.1+RP.2 - if they refer to a URL (see v2.6)",
"identity": "v2"
}, {
"map": "./reference/literal",
"identity": "rim"
} ],
"type": [ {
"code": "url"
} ],
"max": "1",
"id": "Composition.extension:presentedForm.value[x].url",
"comment": "If both data and url are provided, the url SHALL point to the same content as the data contains. Urls may be relative references or may reference transient locations such as a wrapping envelope using cid: though this has ramifications for using signatures. Relative URLs are interpreted relative to the service url, like a resource reference, rather than relative to the resource itself. If a URL is provided, it SHALL resolve to actual data.",
"example": [ {
"label": "General",
"valueUrl": "http://www.acme.com/logo-small.png"
} ],
"base": {
"max": "1",
"min": 0,
"path": "Attachment.url"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.extension.value[x].size",
"requirements": "Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.",
"min": 0,
"definition": "The number of bytes of data that make up this attachment (before base64 encoding, if that is done).",
"isModifier": false,
"short": "Number of bytes of content (if url provided)",
"mapping": [ {
"map": "N/A (needs data type R3 proposal)",
"identity": "rim"
} ],
"type": [ {
"code": "unsignedInt"
} ],
"max": "1",
"id": "Composition.extension:presentedForm.value[x].size",
"comment": "The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference.",
"base": {
"max": "1",
"min": 0,
"path": "Attachment.size"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.extension.value[x].hash",
"requirements": "Included so that applications can verify that the contents of a location have not changed due to technical failures (e.g., storage rot, transport glitch, incorrect version).",
"min": 0,
"definition": "The calculated hash of the data using SHA-1. Represented using base64.",
"isModifier": false,
"short": "Hash of the data (sha-1, base64ed)",
"mapping": [ {
"map": ".integrityCheck[parent::ED/integrityCheckAlgorithm=\"SHA-1\"]",
"identity": "rim"
} ],
"type": [ {
"code": "base64Binary"
} ],
"max": "1",
"id": "Composition.extension:presentedForm.value[x].hash",
"comment": "The hash is calculated on the data prior to base64 encoding, if the data is based64 encoded. The hash is not intended to support digital signatures. Where protection against malicious threats a digital signature should be considered, see [Provenance.signature](http://hl7.org/fhir/R4/provenance-definitions.html#Provenance.signature) for mechanism to protect a resource with a digital signature.",
"base": {
"max": "1",
"min": 0,
"path": "Attachment.hash"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.extension.value[x].title",
"requirements": "Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.",
"min": 0,
"definition": "A label or set of text to display in place of the data.",
"isModifier": false,
"short": "Label to display in place of the data",
"mapping": [ {
"map": "./title/data",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable",
"valueBoolean": true
} ],
"max": "1",
"id": "Composition.extension:presentedForm.value[x].title",
"example": [ {
"label": "General",
"valueString": "Official Corporate Logo"
} ],
"base": {
"max": "1",
"min": 0,
"path": "Attachment.title"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.extension.value[x].creation",
"requirements": "This is often tracked as an integrity issue for use of the attachment.",
"min": 0,
"definition": "The date that the attachment was first created.",
"isModifier": false,
"short": "Date attachment was first created",
"mapping": [ {
"map": "N/A (needs data type R3 proposal)",
"identity": "rim"
} ],
"type": [ {
"code": "dateTime"
} ],
"max": "1",
"id": "Composition.extension:presentedForm.value[x].creation",
"base": {
"max": "1",
"min": 0,
"path": "Attachment.creation"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.extension",
"min": 0,
"definition": "Optional Extension Element - found in all resources.",
"isModifier": false,
"short": "Optional Extensions Element",
"mapping": [ {
"map": "n/a",
"identity": "rim"
}, {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version" ]
} ],
"sliceName": "compositionVersionR5",
"max": "*",
"id": "Composition.extension:compositionVersionR5",
"condition": [ "ele-1" ],
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
},
"isSummary": false
}, {
"path": "Composition.extension.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.extension:compositionVersionR5.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.extension.extension",
"min": 0,
"definition": "An Extension",
"isModifier": false,
"short": "Extension",
"slicing": {
"rules": "open",
"description": "Extensions are always sliced by (at least) url",
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"max": "0",
"id": "Composition.extension:compositionVersionR5.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "Composition.extension.url",
"min": 1,
"definition": "Source of the definition for the extension code - a logical name or a URL.",
"isModifier": false,
"short": "identifies the meaning of the extension",
"fixedUri": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "uri"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.extension:compositionVersionR5.url",
"comment": "The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.",
"base": {
"max": "1",
"min": 1,
"path": "Extension.url"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.extension.value[x]",
"min": 1,
"definition": "Value of extension - must be one of a constrained set of the data types (see [Extensibility](http://hl7.org/fhir/R4/extensibility.html) for a list).",
"isModifier": false,
"short": "Business version",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Composition.extension:compositionVersionR5.value[x]",
"base": {
"max": "1",
"min": 0,
"path": "Extension.value[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.extension",
"min": 0,
"definition": "This extension applies to the Composition resource and is used to represent an intended recipient of the composition.",
"isModifier": false,
"short": "Composition: Information recipient",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.eu/fhir/StructureDefinition/information-recipient" ]
} ],
"sliceName": "information-recipient",
"max": "*",
"id": "Composition.extension:information-recipient",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
},
"isSummary": false
}, {
"path": "Composition.extension.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "id"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.extension:information-recipient.id",
"condition": [ "ele-1" ],
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.extension.extension",
"min": 0,
"definition": "An Extension",
"isModifier": false,
"short": "Extension",
"slicing": {
"rules": "open",
"description": "Extensions are always sliced by (at least) url",
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"max": "0",
"id": "Composition.extension:information-recipient.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"path": "Composition.extension.url",
"min": 1,
"definition": "Source of the definition for the extension code - a logical name or a URL.",
"isModifier": false,
"short": "identifies the meaning of the extension",
"fixedUri": "http://hl7.eu/fhir/StructureDefinition/information-recipient",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "uri"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.extension:information-recipient.url",
"comment": "The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.",
"base": {
"max": "1",
"min": 1,
"path": "Extension.url"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.extension.value[x]",
"min": 0,
"definition": "Value of extension - must be one of a constrained set of the data types (see [Extensibility](http://hl7.org/fhir/R5/extensibility.html) for a list).",
"isModifier": false,
"short": "Value of extension",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/base/StructureDefinition/practitionerRole-eu-core", "http://hl7.eu/fhir/base/StructureDefinition/practitioner-eu-core", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.eu/fhir/base/StructureDefinition/patient-eu-core", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.eu/fhir/base/StructureDefinition/organization-eu-core" ]
} ],
"max": "1",
"id": "Composition.extension:information-recipient.value[x]",
"condition": [ "ext-1" ],
"base": {
"max": "1",
"min": 0,
"path": "Extension.value[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them",
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.identifier",
"min": 0,
"definition": "A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.",
"isModifier": false,
"short": "HDR business identifier",
"mapping": [ {
"map": "Event.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
}, {
"map": "Document.id / Document.setId",
"identity": "rim"
}, {
"map": ".setId",
"identity": "cda"
}, {
"map": "DocumentReference.masterIdentifier",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "Identifier"
} ],
"max": "1",
"id": "Composition.identifier",
"comment": "Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.identifier"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.status",
"requirements": "Need to be able to mark interim, amended, or withdrawn compositions or documents.",
"min": 1,
"definition": "The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.",
"isModifier": true,
"short": "HDR status",
"mapping": [ {
"map": "Event.status",
"identity": "workflow"
}, {
"map": "FiveWs.status",
"identity": "w5"
}, {
"map": "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\"",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
}, {
"map": "DocumentReference.status",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/composition-status|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionStatus"
} ],
"description": "The workflow/clinical status of the composition."
},
"max": "1",
"id": "Composition.status",
"comment": "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. \n\nSome 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.",
"base": {
"max": "1",
"min": 1,
"path": "Composition.status"
},
"isModifierReason": "This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.type",
"requirements": "Key metadata element describing the composition, used in searching/filtering.",
"min": 1,
"definition": "Specifies that this composition refer to a Hospital Discharge Report",
"isModifier": false,
"short": "Kind of composition (\"Hospital Discharge Report\")",
"mapping": [ {
"map": "Event.code",
"identity": "workflow"
}, {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
}, {
"map": "DocumentReference.type",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-typecodes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DocumentType"
} ],
"description": "Type of a composition."
},
"max": "1",
"id": "Composition.type",
"comment": "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.",
"patternCodeableConcept": {
"coding": [ {
"code": "34105-7",
"system": "http://loinc.org",
"display": "Hospital Discharge summary"
} ]
},
"base": {
"max": "1",
"min": 1,
"path": "Composition.type"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.category",
"requirements": "Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.",
"min": 0,
"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.",
"isModifier": false,
"short": "Categorization of Composition",
"mapping": [ {
"map": "Event.subject",
"identity": "workflow"
}, {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
}, {
"map": "DocumenttReference.category",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/document-classcodes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DocumentCategory"
} ],
"description": "High-level kind of a clinical document at a macro level."
},
"max": "*",
"id": "Composition.category",
"comment": "This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)).",
"base": {
"max": "*",
"min": 0,
"path": "Composition.category"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.subject",
"requirements": "Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.",
"min": 1,
"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 hdr the subject is always the patient.",
"isModifier": false,
"short": "Who and/or what the composition is about",
"mapping": [ {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]",
"identity": "rim"
}, {
"map": ".recordTarget",
"identity": "cda"
}, {
"map": "DocumentReference.subject",
"identity": "fhirdocumentreference"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/base/StructureDefinition/patient-eu-core" ]
} ],
"max": "1",
"id": "Composition.subject",
"comment": "For clinical documents, this is usually the patient.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.subject"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.encounter",
"requirements": "Provides context for the composition and supports searching.",
"min": 0,
"definition": "Describes the clinical encounter or type of care this documentation is associated with.",
"isModifier": false,
"short": "Context of the Composition",
"mapping": [ {
"map": "Event.context",
"identity": "workflow"
}, {
"map": "FiveWs.context",
"identity": "w5"
}, {
"map": "unique(highest(./outboundRelationship[typeCode=\"SUBJ\" and isNormalActRelationship()], priorityNumber)/target[moodCode=\"EVN\" and classCode=(\"ENC\", \"PCPR\") and isNormalAct])",
"identity": "rim"
}, {
"map": ".componentOf.encompassingEncounter",
"identity": "cda"
}, {
"map": "DocumentReference.context.encounter",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/encounter-eu-hdr" ]
} ],
"max": "1",
"id": "Composition.encounter",
"base": {
"max": "1",
"min": 0,
"path": "Composition.encounter"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.date",
"requirements": "dateTime is used for tracking, organizing versions and searching. Note that this is the time of *authoring*. When packaged in a document, [Bundle.timestamp](http://hl7.org/fhir/R4/bundle-definitions.html#Bundle.timestamp) is the date of packaging.",
"min": 1,
"definition": "The composition editing time, when the composition was last logically changed by the author.",
"isModifier": false,
"short": "HDR date",
"mapping": [ {
"map": "Event.occurrence[x]",
"identity": "workflow"
}, {
"map": "FiveWs.done[x]",
"identity": "w5"
}, {
"map": ".effectiveTime[type=\"TS\"]",
"identity": "rim"
}, {
"map": ".effectiveTime",
"identity": "cda"
}, {
"map": "DocumentReference.content.attachment.date, DocumentReference.created",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "dateTime"
} ],
"max": "1",
"id": "Composition.date",
"comment": "The Last Modified Date on the composition may be after the date of the document was attested without being changed.",
"base": {
"max": "1",
"min": 1,
"path": "Composition.date"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.author",
"requirements": "Identifies who is responsible for the content.",
"min": 1,
"definition": "Identifies who is responsible for the information in the Hospital Discharge Report, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the Hospital Discharge Report",
"mapping": [ {
"map": "Event.performer",
"identity": "workflow"
}, {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
}, {
"map": "DocumentReference.agent",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/base/StructureDefinition/practitioner-eu-core", "http://hl7.eu/fhir/base/StructureDefinition/practitionerRole-eu-core", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.eu/fhir/base/StructureDefinition/organization-eu-core" ]
} ],
"max": "*",
"id": "Composition.author",
"base": {
"max": "*",
"min": 1,
"path": "Composition.author"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.title",
"min": 1,
"definition": "Official human-readable label for the composition.\r\n\r\nFor this document should be \"Hospital Discharge Report\" or any equivalent translation",
"isModifier": false,
"short": "Hospital Discharge Report",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
}, {
"map": "DocumentReference.description, DocumentReference.content.attachment.title",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Composition.title",
"comment": "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.",
"base": {
"max": "1",
"min": 1,
"path": "Composition.title"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.confidentiality",
"min": 0,
"definition": "The code specifying the level of confidentiality of the Composition.",
"isModifier": false,
"short": "As defined by affinity domain",
"mapping": [ {
"map": ".confidentialityCode",
"identity": "rim"
}, {
"map": ".confidentialityCode",
"identity": "cda"
}, {
"map": "DocumentReference.securityLabel",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DocumentConfidentiality"
} ],
"description": "Codes specifying the level of confidentiality of the composition."
},
"max": "1",
"id": "Composition.confidentiality",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.confidentiality"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.attester",
"requirements": "Identifies responsibility for the accuracy of the composition content.",
"min": 0,
"definition": "A participant who has attested to the accuracy of the composition/document.",
"isModifier": false,
"short": "Attests to accuracy of composition",
"mapping": [ {
"map": ".participation[typeCode=\"AUTHEN\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".authenticator/.legalAuthenticator",
"identity": "cda"
}, {
"map": "DocumentReference.authenticator",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"max": "*",
"id": "Composition.attester",
"comment": "Only list each attester once.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.attester"
},
"isSummary": false
}, {
"path": "Composition.attester.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.attester.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.attester.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.attester.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.attester.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.attester.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.attester.mode",
"requirements": "Indicates the level of authority of the attestation.",
"min": 1,
"definition": "The type of attestation the authenticator offers.",
"isModifier": false,
"short": "The type of attestation",
"mapping": [ {
"map": "unique(./modeCode)",
"identity": "rim"
}, {
"map": "implied by .authenticator/.legalAuthenticator",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionAttestationMode"
} ],
"description": "The way in which a person authenticated a composition."
},
"max": "1",
"id": "Composition.attester.mode",
"base": {
"max": "1",
"min": 1,
"path": "Composition.attester.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.attester.time",
"requirements": "Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).",
"min": 0,
"definition": "When the composition was attested by the party.",
"isModifier": false,
"short": "When the composition was attested.",
"mapping": [ {
"map": "./time[type=\"TS\" and isNormalDatatype()]",
"identity": "rim"
}, {
"map": ".authenticator.time",
"identity": "cda"
} ],
"type": [ {
"code": "dateTime"
} ],
"max": "1",
"id": "Composition.attester.time",
"base": {
"max": "1",
"min": 0,
"path": "Composition.attester.time"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.attester.party",
"requirements": "Identifies who has taken on the responsibility for accuracy of the composition content.",
"min": 0,
"definition": "Who attested the composition in the specified way.",
"isModifier": false,
"short": "Who attested the composition.",
"mapping": [ {
"map": "FiveWs.witness",
"identity": "w5"
}, {
"map": "./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()]",
"identity": "rim"
}, {
"map": ".authenticator.assignedEnttty",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/base/StructureDefinition/practitioner-eu-core", "http://hl7.eu/fhir/base/StructureDefinition/practitionerRole-eu-core", "http://hl7.eu/fhir/base/StructureDefinition/organization-eu-core" ]
} ],
"max": "1",
"id": "Composition.attester.party",
"base": {
"max": "1",
"min": 0,
"path": "Composition.attester.party"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.custodian",
"requirements": "Identifies where to go to find the current version, where to report issues, etc.",
"min": 0,
"definition": "Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.",
"isModifier": false,
"short": "Organization which maintains the composition",
"mapping": [ {
"map": ".participation[typeCode=\"RCV\"].role[classCode=\"CUST\"].scoper[classCode=\"ORG\" and determinerCode=\"INST\"]",
"identity": "rim"
}, {
"map": ".custodian.assignedCustodian",
"identity": "cda"
}, {
"map": "DocumentReference.custodian",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "1",
"id": "Composition.custodian",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.custodian"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.relatesTo",
"min": 0,
"definition": "Relationships that this composition has with other compositions or documents that already exist.",
"isModifier": false,
"short": "Relationships to other compositions/documents",
"mapping": [ {
"map": ".outboundRelationship",
"identity": "rim"
}, {
"map": ".relatedDocument",
"identity": "cda"
}, {
"map": "DocumentReference.relatesTo",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"max": "*",
"id": "Composition.relatesTo",
"comment": "A document is a version specific composition.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.relatesTo"
},
"isSummary": false
}, {
"path": "Composition.relatesTo.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.relatesTo.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.relatesTo.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.relatesTo.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.relatesTo.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.relatesTo.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.relatesTo.code",
"min": 1,
"definition": "The type of relationship that this composition has with anther composition or document.",
"isModifier": false,
"short": "replaces | transforms | signs | appends",
"mapping": [ {
"map": ".outboundRelationship.typeCode",
"identity": "rim"
}, {
"map": ".relatedDocument.typeCode",
"identity": "cda"
}, {
"map": "DocumentReference.relatesTo.code",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DocumentRelationshipType"
} ],
"description": "The type of relationship between documents."
},
"max": "1",
"id": "Composition.relatesTo.code",
"comment": "If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.",
"base": {
"max": "1",
"min": 1,
"path": "Composition.relatesTo.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.relatesTo.target[x]",
"min": 1,
"definition": "The target composition/document of this relationship.",
"isModifier": false,
"short": "Target of the relationship",
"mapping": [ {
"map": ".target[classCode=\"DOC\", moodCode=\"EVN\"].id",
"identity": "rim"
}, {
"map": ".relatedDocument.id",
"identity": "cda"
}, {
"map": "DocumentReference.relatesTo.target",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "Identifier"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Composition" ]
} ],
"max": "1",
"id": "Composition.relatesTo.target[x]",
"base": {
"max": "1",
"min": 1,
"path": "Composition.relatesTo.target[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.event",
"requirements": "Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.",
"min": 0,
"definition": "The clinical service, such as a colonoscopy or an appendectomy, being documented.",
"isModifier": false,
"short": "The clinical service(s) being documented",
"mapping": [ {
"map": "outboundRelationship[typeCode=\"SUBJ\"].target[classCode<'ACT']",
"identity": "rim"
}, {
"map": ".documentationOf.serviceEvent",
"identity": "cda"
}, {
"map": "DocumentReference.event",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"max": "*",
"id": "Composition.event",
"comment": "The event needs to be consistent with the type element, though can provide further information if desired.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.event"
},
"isSummary": true
}, {
"path": "Composition.event.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.event.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.event.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.event.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.event.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.event.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.event.code",
"min": 0,
"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.",
"isModifier": false,
"short": "Code(s) that apply to the event being documented",
"mapping": [ {
"map": ".code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
}, {
"map": "DocumentReference.event.code",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://terminology.hl7.org/ValueSet/v3-ActCode",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DocumentEventType"
} ],
"description": "This list of codes represents the main clinical acts being documented."
},
"max": "*",
"id": "Composition.event.code",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.event.code"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.event.period",
"min": 0,
"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.",
"isModifier": false,
"short": "The period covered by the documentation",
"mapping": [ {
"map": ".effectiveTime",
"identity": "rim"
}, {
"map": ".effectiveTime",
"identity": "cda"
}, {
"map": "DocumentReference.event.period",
"identity": "fhirdocumentreference"
} ],
"type": [ {
"code": "Period"
} ],
"max": "1",
"id": "Composition.event.period",
"base": {
"max": "1",
"min": 0,
"path": "Composition.event.period"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.event.detail",
"min": 0,
"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.",
"isModifier": false,
"short": "The event(s) being documented",
"mapping": [ {
"map": ".outboundRelationship[typeCode=\"SUBJ\"].target",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "*",
"id": "Composition.event.detail",
"base": {
"max": "*",
"min": 0,
"path": "Composition.event.detail"
},
"isSummary": true
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 1,
"definition": "The root of the sections that make up the Hospital Discharge Report composition.",
"isModifier": false,
"short": "Sections composing the Hospital Discharge Report",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "code",
"type": "value"
} ]
},
"type": [ {
"code": "BackboneElement"
} ],
"max": "*",
"id": "Composition.section",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 0,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 0,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section.code",
"comment": "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. \n\nIf 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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "*",
"id": "Composition.section.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "Hospital Admission evaluation",
"isModifier": false,
"short": "Hospital Admission evaluation",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionAdmissionEvaluation",
"max": "1",
"id": "Composition.section:sectionAdmissionEvaluation",
"comment": "Admission evaluation should be reported only exceptionally, if it is relevant to ensure continuity of care.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionAdmissionEvaluation.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionAdmissionEvaluation.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionAdmissionEvaluation.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionAdmissionEvaluation.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionAdmissionEvaluation.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "67851-6",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionAdmissionEvaluation.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionAdmissionEvaluation.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionAdmissionEvaluation.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionAdmissionEvaluation.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionAdmissionEvaluation.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "*",
"id": "Composition.section:sectionAdmissionEvaluation.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionAdmissionEvaluation.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionAdmissionEvaluation.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "Anthropometric Observations sub-section",
"isModifier": false,
"short": "Anthropometric observations",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionAnthropometry",
"max": "1",
"id": "Composition.section:sectionAnthropometry",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionAnthropometry.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionAnthropometry.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionAnthropometry.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionAnthropometry.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionAnthropometry.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "anthropometry",
"system": "http://hl7.eu/fhir/hdr/CodeSystem/temporarySystem-hdr-eu"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionAnthropometry.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionAnthropometry.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionAnthropometry.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionAnthropometry.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionAnthropometry.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/DocumentReference", "http://hl7.org/fhir/StructureDefinition/vitalsigns" ]
} ],
"max": "*",
"id": "Composition.section:sectionAnthropometry.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionAnthropometry.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionAnthropometry.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"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",
"isModifier": false,
"short": "Vital signs",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionVitalSigns",
"max": "1",
"id": "Composition.section:sectionVitalSigns",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionVitalSigns.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionVitalSigns.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionVitalSigns.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionVitalSigns.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionVitalSigns.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "8716-3",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionVitalSigns.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionVitalSigns.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionVitalSigns.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionVitalSigns.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionVitalSigns.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/DocumentReference", "http://hl7.org/fhir/StructureDefinition/vitalsigns" ]
} ],
"max": "*",
"id": "Composition.section:sectionVitalSigns.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionVitalSigns.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionVitalSigns.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "Physical findings",
"isModifier": false,
"short": "Physical findings",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionPhysicalFindings",
"max": "1",
"id": "Composition.section:sectionPhysicalFindings",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionPhysicalFindings.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionPhysicalFindings.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionPhysicalFindings.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionPhysicalFindings.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionPhysicalFindings.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "29545-1",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionPhysicalFindings.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionPhysicalFindings.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionPhysicalFindings.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionPhysicalFindings.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionPhysicalFindings.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "*",
"id": "Composition.section:sectionPhysicalFindings.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionPhysicalFindings.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionPhysicalFindings.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"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.",
"isModifier": false,
"short": "Functional status",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionFunctionalStatus",
"max": "1",
"id": "Composition.section:sectionFunctionalStatus",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionFunctionalStatus.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionFunctionalStatus.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionFunctionalStatus.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionFunctionalStatus.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionFunctionalStatus.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "47420-5",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionFunctionalStatus.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionFunctionalStatus.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionFunctionalStatus.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionFunctionalStatus.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionFunctionalStatus.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"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.",
"isModifier": false,
"short": "Optional entry used to represent disabilities and functional assessments",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Condition", "http://hl7.org/fhir/StructureDefinition/ClinicalImpression", "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/DocumentReference", "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse" ]
} ],
"max": "*",
"id": "Composition.section:sectionFunctionalStatus.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionFunctionalStatus.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionFunctionalStatus.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 1,
"definition": "This section includes basic information about hospital staty (encounter), diagnostic summary in narrative form, pharmacotherapy, major procedures, medical devices, significant findings during hospital stay and clinical synthesis.",
"isModifier": false,
"short": "Significant information about course of hospital stay",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionHospitalCourse",
"max": "1",
"id": "Composition.section:sectionHospitalCourse",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionHospitalCourse.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionHospitalCourse.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionHospitalCourse.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionHospitalCourse.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionHospitalCourse.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "8648-8",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionHospitalCourse.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionHospitalCourse.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionHospitalCourse.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionHospitalCourse.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionHospitalCourse.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "*",
"id": "Composition.section:sectionHospitalCourse.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionHospitalCourse.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionHospitalCourse.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section.",
"isModifier": false,
"short": "Problem specification in narrative form",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionDiagnosticSummary",
"max": "1",
"id": "Composition.section:sectionDiagnosticSummary",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionDiagnosticSummary.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionDiagnosticSummary.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionDiagnosticSummary.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionDiagnosticSummary.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionDiagnosticSummary.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "11535-2",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionDiagnosticSummary.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionDiagnosticSummary.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionDiagnosticSummary.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionDiagnosticSummary.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionDiagnosticSummary.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/condition-eu-hdr" ]
} ],
"max": "*",
"id": "Composition.section:sectionDiagnosticSummary.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionDiagnosticSummary.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionDiagnosticSummary.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "Significant surgical and non-surgical procedures performed during hospitalisation which are significant for continuity of care, e.g. surgeries and other \"instrumental\"interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others.\r\nThis section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data.",
"isModifier": false,
"short": "Significant procedures",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionSignificantProcedures",
"max": "1",
"id": "Composition.section:sectionSignificantProcedures",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionSignificantProcedures.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionSignificantProcedures.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionSignificantProcedures.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionSignificantProcedures.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionSignificantProcedures.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "10185-7",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionSignificantProcedures.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionSignificantProcedures.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionSignificantProcedures.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionSignificantProcedures.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionSignificantProcedures.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/procedure-eu-hdr" ]
} ],
"max": "*",
"id": "Composition.section:sectionSignificantProcedures.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionSignificantProcedures.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "0",
"id": "Composition.section:sectionSignificantProcedures.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during hospitalisation. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system.",
"isModifier": false,
"short": "Medical devices and implants",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionMedicalDevices",
"max": "1",
"id": "Composition.section:sectionMedicalDevices",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionMedicalDevices.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionMedicalDevices.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionMedicalDevices.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionMedicalDevices.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionMedicalDevices.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "57080-4",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionMedicalDevices.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionMedicalDevices.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionMedicalDevices.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionMedicalDevices.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionMedicalDevices.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/deviceUseStatement-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/procedure-eu-hdr" ]
} ],
"max": "*",
"id": "Composition.section:sectionMedicalDevices.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionMedicalDevices.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "0",
"id": "Composition.section:sectionMedicalDevices.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "Selected drug treatment during hospitalisation. Medicinal products that were administered during hospitalisation and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section.\r\nMedicinal products, the administration of which was started during hospitalisation but is also recommended after discharge, will be listed in the summary table in the recommendation section.",
"isModifier": false,
"short": "Pharmacotherapy",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionPharmacotherapy",
"max": "1",
"id": "Composition.section:sectionPharmacotherapy",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionPharmacotherapy.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionPharmacotherapy.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionPharmacotherapy.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionPharmacotherapy.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionPharmacotherapy.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "87232-5",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionPharmacotherapy.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionPharmacotherapy.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionPharmacotherapy.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionPharmacotherapy.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionPharmacotherapy.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/medicationStatement-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/medicationRequest-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/medicationDispense-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/medicationAdministration-eu-hdr" ]
} ],
"max": "*",
"id": "Composition.section:sectionPharmacotherapy.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionPharmacotherapy.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionPharmacotherapy.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during hospitalisation. Results of examinations ordered but not yet delivered should be presented separately from results already delivered.",
"isModifier": false,
"short": "Significant Observation Results",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionSignificantResults",
"max": "1",
"id": "Composition.section:sectionSignificantResults",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionSignificantResults.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionSignificantResults.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionSignificantResults.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionSignificantResults.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionSignificantResults.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "30954-2",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionSignificantResults.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionSignificantResults.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionSignificantResults.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionSignificantResults.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionSignificantResults.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "significant results",
"isModifier": false,
"short": "significant results",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/DiagnosticReport", "http://hl7.org/fhir/StructureDefinition/DocumentReference" ]
} ],
"max": "*",
"id": "Composition.section:sectionSignificantResults.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "Laboratory Result",
"isModifier": false,
"short": "Laboratory Result",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/laboratory/StructureDefinition/Observation-resultslab-eu-lab" ]
} ],
"sliceName": "labResult",
"max": "*",
"id": "Composition.section:sectionSignificantResults.entry:labResult",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "Radiology Result",
"isModifier": false,
"short": "Radiology Result",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/observation-imgFinding-eu-hdr" ]
} ],
"sliceName": "radResult",
"max": "*",
"id": "Composition.section:sectionSignificantResults.entry:radResult",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionSignificantResults.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionSignificantResults.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "This section provides clinical synthesis (e.g. description of reasons and course of hospital stay) clustered by managed conditions. Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions.",
"isModifier": false,
"short": "Synthesis",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionSynthesis",
"max": "1",
"id": "Composition.section:sectionSynthesis",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionSynthesis.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionSynthesis.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionSynthesis.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionSynthesis.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionSynthesis.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "67781-5",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionSynthesis.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionSynthesis.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionSynthesis.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionSynthesis.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionSynthesis.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "*",
"id": "Composition.section:sectionSynthesis.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionSynthesis.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionSynthesis.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"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.",
"isModifier": false,
"short": "Plan of Care Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionPlanOfCare",
"max": "1",
"id": "Composition.section:sectionPlanOfCare",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionPlanOfCare.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionPlanOfCare.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionPlanOfCare.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionPlanOfCare.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionPlanOfCare.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "18776-5",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionPlanOfCare.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionPlanOfCare.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionPlanOfCare.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionPlanOfCare.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionPlanOfCare.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/carePlan-eu-hdr", "http://hl7.org/fhir/StructureDefinition/DocumentReference" ]
} ],
"max": "*",
"id": "Composition.section:sectionPlanOfCare.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionPlanOfCare.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionPlanOfCare.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "Hospital Discharge Instructions",
"isModifier": false,
"short": "Hospital Discharge Instructions",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionDischargeInstructions",
"max": "1",
"id": "Composition.section:sectionDischargeInstructions",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionDischargeInstructions.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionDischargeInstructions.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionDischargeInstructions.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionDischargeInstructions.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionDischargeInstructions.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "8653-8",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionDischargeInstructions.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionDischargeInstructions.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionDischargeInstructions.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionDischargeInstructions.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionDischargeInstructions.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "*",
"id": "Composition.section:sectionDischargeInstructions.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionDischargeInstructions.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionDischargeInstructions.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "Hospital discharge medications defines the medications that the patient is intended to take, or stop, after discharge",
"isModifier": false,
"short": "Hospital discharge medications",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionDischargeMedications",
"max": "1",
"id": "Composition.section:sectionDischargeMedications",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionDischargeMedications.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionDischargeMedications.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionDischargeMedications.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionDischargeMedications.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionDischargeMedications.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "75311-1",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionDischargeMedications.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionDischargeMedications.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionDischargeMedications.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionDischargeMedications.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionDischargeMedications.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/medicationRequest-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/medicationDispense-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/medicationStatement-eu-hdr" ]
} ],
"max": "*",
"id": "Composition.section:sectionDischargeMedications.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionDischargeMedications.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionDischargeMedications.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"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.",
"isModifier": false,
"short": "Allergies and Intolerances Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionAllergies",
"max": "1",
"id": "Composition.section:sectionAllergies",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionAllergies.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionAllergies.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionAllergies.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionAllergies.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionAllergies.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "48765-2",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionAllergies.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionAllergies.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionAllergies.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionAllergies.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionAllergies.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"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.\r\n This entry shall be used to document that no information about allergies is available, or that no allergies are known .",
"isModifier": false,
"short": "Relevant allergies or intolerances (conditions) for that patient.",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "resolve()",
"type": "type"
} ]
},
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/allergyIntolerance-eu-hdr", "http://hl7.org/fhir/StructureDefinition/DocumentReference" ]
} ],
"max": "*",
"id": "Composition.section:sectionAllergies.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "Allergy entry",
"isModifier": false,
"short": "Allergy entry",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/allergyIntolerance-eu-hdr" ]
} ],
"sliceName": "allergyIntolerance",
"max": "*",
"id": "Composition.section:sectionAllergies.entry:allergyIntolerance",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionAllergies.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionAllergies.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "// SHORT\r\n A warning, other than included in allergies.\r\n The warning can be entered in code there are codes for frequently used alerts but seeing the dynamic nature of the warnings, these alerts will often be entered as free text.\r\n Any clinical information that is imperative to know so that the life or health of the patient does not come under threat. \r\n Example 1: the patient has a rare disease that requires special treatment \r\n Example 2: Airway Alert / Difficult Intubation\r\n Example 3: Diagnoses such as malignant hyperthermia, porphyria, and bleeding disorders; special treatments like anticoagulants or immunosuppressants; implanted devices. \r\n Example 4: transplanted organs illustrate other information that has to be taken into account in a healthcare contact. \r\n Example 5: participation in a clinical trial that has to be taken into account in a healthcare contact.",
"isModifier": false,
"short": "Alert Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionAlert",
"max": "1",
"id": "Composition.section:sectionAlert",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionAlert.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionAlert.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionAlert.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionAlert.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionAlert.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "104605-1",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionAlert.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionAlert.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionAlert.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionAlert.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionAlert.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "Alerts",
"isModifier": false,
"short": "Alerts",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "resolve()",
"type": "type"
} ]
},
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "*",
"id": "Composition.section:sectionAlert.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "Flags",
"isModifier": false,
"short": "Flags",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Flag" ]
} ],
"sliceName": "flag",
"max": "*",
"id": "Composition.section:sectionAlert.entry:flag",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionAlert.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionAlert.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "This section includes heath insurance and payment information.",
"isModifier": false,
"short": "Health insurance and payment information.",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionPayers",
"max": "1",
"id": "Composition.section:sectionPayers",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionPayers.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionPayers.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionPayers.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionPayers.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionPayers.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "48768-6",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionPayers.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionPayers.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionPayers.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionPayers.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionPayers.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Coverage" ]
} ],
"max": "*",
"id": "Composition.section:sectionPayers.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionPayers.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionPayers.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "This Section describes all aspects of the medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. The history may be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections including Past Medical History, Social History.",
"isModifier": false,
"short": "Patient history Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionPatientHx",
"max": "1",
"id": "Composition.section:sectionPatientHx",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionPatientHx.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionPatientHx.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionPatientHx.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionPatientHx.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionPatientHx.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "35090-0",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionPatientHx.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionPatientHx.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionPatientHx.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionPatientHx.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionPatientHx.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "*",
"id": "Composition.section:sectionPatientHx.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionPatientHx.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionPatientHx.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "The IPS derived problem section lists and describes clinical problems or conditions currently being monitored for the patient.",
"isModifier": false,
"short": "Problem List Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionProblemList",
"max": "1",
"id": "Composition.section:sectionProblemList",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionProblemList.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionProblemList.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionProblemList.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionProblemList.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionProblemList.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "11450-4",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionProblemList.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionProblemList.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionProblemList.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionProblemList.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionProblemList.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "It contains a description of the conditions the patient suffered in the past.",
"isModifier": false,
"short": "Conditions the patient suffered in the past.",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/condition-eu-hdr" ]
} ],
"max": "*",
"id": "Composition.section:sectionProblemList.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionProblemList.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionProblemList.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "The History of Past Illness section contains a narrative description and coded entries of the conditions the patient suffered in the past",
"isModifier": false,
"short": "History of Past Illness Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionPastIllnessHx",
"max": "1",
"id": "Composition.section:sectionPastIllnessHx",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionPastIllnessHx.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionPastIllnessHx.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionPastIllnessHx.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionPastIllnessHx.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionPastIllnessHx.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "11348-0",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionPastIllnessHx.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionPastIllnessHx.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionPastIllnessHx.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionPastIllnessHx.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionPastIllnessHx.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "It contains a description of the conditions the patient suffered in the past.",
"isModifier": false,
"short": "Conditions the patient suffered in the past.",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/condition-eu-hdr" ]
} ],
"max": "*",
"id": "Composition.section:sectionPastIllnessHx.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionPastIllnessHx.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionPastIllnessHx.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "The medical devices section contains narrative text and coded entries describing the patient history of medical device use.",
"isModifier": false,
"short": "History of Medical devices and implants",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionHistoryMedicalDevices",
"max": "1",
"id": "Composition.section:sectionHistoryMedicalDevices",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionHistoryMedicalDevices.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionHistoryMedicalDevices.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionHistoryMedicalDevices.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionHistoryMedicalDevices.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionHistoryMedicalDevices.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "46264-8",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionHistoryMedicalDevices.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionHistoryMedicalDevices.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionHistoryMedicalDevices.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionHistoryMedicalDevices.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionHistoryMedicalDevices.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/deviceUseStatement-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/procedure-eu-hdr" ]
} ],
"max": "*",
"id": "Composition.section:sectionHistoryMedicalDevices.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionHistoryMedicalDevices.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "0",
"id": "Composition.section:sectionHistoryMedicalDevices.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"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",
"isModifier": false,
"short": "History of Procedures Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionProceduresHx",
"max": "1",
"id": "Composition.section:sectionProceduresHx",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionProceduresHx.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionProceduresHx.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionProceduresHx.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionProceduresHx.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionProceduresHx.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "47519-4",
"system": "http://loinc.org",
"display": "History of Procedures Document"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionProceduresHx.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionProceduresHx.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionProceduresHx.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionProceduresHx.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionProceduresHx.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"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. This entry shall be used to document that no information about past procedures is available, or that no relevant past procedures are known.",
"isModifier": false,
"short": "Patient past procedures pertinent to the scope of this document.",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/procedure-eu-hdr" ]
} ],
"max": "*",
"id": "Composition.section:sectionProceduresHx.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionProceduresHx.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionProceduresHx.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"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 current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.",
"isModifier": false,
"short": "Immunizations Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionImmunizations",
"max": "1",
"id": "Composition.section:sectionImmunizations",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionImmunizations.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionImmunizations.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionImmunizations.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionImmunizations.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionImmunizations.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "11369-6",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionImmunizations.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionImmunizations.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionImmunizations.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionImmunizations.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionImmunizations.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/immunization-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/immunizationRecommendation-eu-hdr", "http://hl7.org/fhir/StructureDefinition/DocumentReference" ]
} ],
"max": "*",
"id": "Composition.section:sectionImmunizations.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionImmunizations.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionImmunizations.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "Infectious contacts of the patient",
"isModifier": false,
"short": "Infectious contacts",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionInfectiousContacts",
"max": "1",
"id": "Composition.section:sectionInfectiousContacts",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionInfectiousContacts.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionInfectiousContacts.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionInfectiousContacts.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionInfectiousContacts.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionInfectiousContacts.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "infection-contact",
"system": "http://hl7.eu/fhir/hdr/CodeSystem/temporarySystem-hdr-eu"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionInfectiousContacts.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionInfectiousContacts.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionInfectiousContacts.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionInfectiousContacts.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionInfectiousContacts.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "Information about a suspected infectious agent or agents the person was exposed to.",
"isModifier": false,
"short": "Exposure to an infectious agent.",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/observation-infectious-contact-eu-hdr" ]
} ],
"max": "*",
"id": "Composition.section:sectionInfectiousContacts.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionInfectiousContacts.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "0",
"id": "Composition.section:sectionInfectiousContacts.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "This Section describes the travel history relevant for the Patient Summary, e.g.recent travel in a region of high prevalence of a specific infectious disease like Malaria",
"isModifier": false,
"short": "Travel History Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionTravelHx",
"max": "1",
"id": "Composition.section:sectionTravelHx",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionTravelHx.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionTravelHx.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionTravelHx.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionTravelHx.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionTravelHx.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "10182-4",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionTravelHx.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionTravelHx.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionTravelHx.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionTravelHx.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionTravelHx.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/observation-travel-eu-hdr" ]
} ],
"max": "*",
"id": "Composition.section:sectionTravelHx.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionTravelHx.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "0",
"id": "Composition.section:sectionTravelHx.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "This section contains data defining the patient’s genetic relatives in terms of possible or relevant health risk factors that have a potential impact on the patient’s healthcare risk profile.",
"isModifier": false,
"short": "Family History Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionFamilyHistory",
"max": "1",
"id": "Composition.section:sectionFamilyHistory",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionFamilyHistory.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionFamilyHistory.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionFamilyHistory.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionFamilyHistory.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionFamilyHistory.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "10157-6",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionFamilyHistory.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionFamilyHistory.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionFamilyHistory.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionFamilyHistory.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionFamilyHistory.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "Family History",
"isModifier": false,
"short": "Family History",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/familyMemberHistory-eu-hdr", "http://hl7.org/fhir/StructureDefinition/DocumentReference" ]
} ],
"max": "*",
"id": "Composition.section:sectionFamilyHistory.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionFamilyHistory.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionFamilyHistory.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "The social history section contains a description of the person Health related lifestyle factors or lifestyle observations. E.g. smoke habits; alcohol consumption; diets, risky habits.",
"isModifier": false,
"short": "Social History Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionSocialHistory",
"max": "1",
"id": "Composition.section:sectionSocialHistory",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionSocialHistory.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionSocialHistory.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionSocialHistory.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionSocialHistory.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionSocialHistory.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "29762-2",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionSocialHistory.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionSocialHistory.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionSocialHistory.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionSocialHistory.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionSocialHistory.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "Information about social determinants of health.",
"isModifier": false,
"short": "Information about social determinants of health.",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "resolve()",
"type": "type"
} ]
},
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/DocumentReference", "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse" ]
} ],
"max": "*",
"id": "Composition.section:sectionSocialHistory.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "Social determinants of health entry",
"isModifier": false,
"short": "SDOH entry",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/observation-sdoh-eu-hdr" ]
} ],
"sliceName": "sdoh",
"max": "*",
"id": "Composition.section:sectionSocialHistory.entry:sdoh",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionSocialHistory.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionSocialHistory.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "The Use of Substances Section contains a description of the use abuse of substances E.g. tobacco; alcohol; drugs",
"isModifier": false,
"short": "Use of Substances Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionSubstanceUse",
"max": "1",
"id": "Composition.section:sectionSubstanceUse",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionSubstanceUse.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionSubstanceUse.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionSubstanceUse.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionSubstanceUse.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionSubstanceUse.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "substance-use",
"system": "http://hl7.eu/fhir/hdr/CodeSystem/temporarySystem-hdr-eu"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionSubstanceUse.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionSubstanceUse.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionSubstanceUse.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionSubstanceUse.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionSubstanceUse.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation" ]
} ],
"max": "*",
"id": "Composition.section:sectionSubstanceUse.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionSubstanceUse.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionSubstanceUse.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "The Alcohol use Section contains a description of the use abuse of alcohol",
"isModifier": false,
"short": "Alcohol use Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionAlcoholUse",
"max": "1",
"id": "Composition.section:sectionAlcoholUse",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionAlcoholUse.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionAlcoholUse.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionAlcoholUse.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionAlcoholUse.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionAlcoholUse.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "11331-6",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionAlcoholUse.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionAlcoholUse.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionAlcoholUse.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionAlcoholUse.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionAlcoholUse.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation" ]
} ],
"max": "*",
"id": "Composition.section:sectionAlcoholUse.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionAlcoholUse.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionAlcoholUse.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "The Tobacco use Section contains a description of the use abuse of tobacco",
"isModifier": false,
"short": "Tobacco use Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionTobaccoUse",
"max": "1",
"id": "Composition.section:sectionTobaccoUse",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionTobaccoUse.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionTobaccoUse.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionTobaccoUse.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionTobaccoUse.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionTobaccoUse.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "11367-0",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionTobaccoUse.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionTobaccoUse.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionTobaccoUse.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionTobaccoUse.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionTobaccoUse.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation" ]
} ],
"max": "*",
"id": "Composition.section:sectionTobaccoUse.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionTobaccoUse.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionTobaccoUse.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "The Drug use Section contains a description of the use abuse of drugs",
"isModifier": false,
"short": "Drug use Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionDrugUse",
"max": "1",
"id": "Composition.section:sectionDrugUse",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionDrugUse.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionDrugUse.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionDrugUse.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionDrugUse.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionDrugUse.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "11343-1",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionDrugUse.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionDrugUse.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionDrugUse.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionDrugUse.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionDrugUse.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation" ]
} ],
"max": "*",
"id": "Composition.section:sectionDrugUse.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionDrugUse.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionDrugUse.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "The hospital discharge status or disposition of the patient having a hospitalization.",
"isModifier": false,
"short": "Discharge details",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionDischargeDetails",
"max": "1",
"id": "Composition.section:sectionDischargeDetails",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionDischargeDetails.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionDischargeDetails.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionDischargeDetails.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionDischargeDetails.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionDischargeDetails.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "8650-4",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionDischargeDetails.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionDischargeDetails.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionDischargeDetails.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionDischargeDetails.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionDischargeDetails.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "*",
"id": "Composition.section:sectionDischargeDetails.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionDischargeDetails.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionDischargeDetails.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "The advance directives section contains a narrative description of patient's advance directive.",
"isModifier": false,
"short": "Advance Directives Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionAdvanceDirectives",
"max": "1",
"id": "Composition.section:sectionAdvanceDirectives",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionAdvanceDirectives.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionAdvanceDirectives.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionAdvanceDirectives.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionAdvanceDirectives.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionAdvanceDirectives.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "42348-3",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionAdvanceDirectives.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionAdvanceDirectives.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionAdvanceDirectives.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionAdvanceDirectives.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionAdvanceDirectives.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/consent-eu-hdr", "http://hl7.org/fhir/StructureDefinition/DocumentReference" ]
} ],
"max": "*",
"id": "Composition.section:sectionAdvanceDirectives.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionAdvanceDirectives.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionAdvanceDirectives.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "// SHORT\r\n The Care Team Section is used to share historical and current Care Team information.",
"isModifier": false,
"short": "Care Team Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionCareTeam",
"max": "1",
"id": "Composition.section:sectionCareTeam",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionCareTeam.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionCareTeam.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionCareTeam.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionCareTeam.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionCareTeam.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "85847-2",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionCareTeam.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionCareTeam.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionCareTeam.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionCareTeam.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionCareTeam.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "Care Teams",
"isModifier": false,
"short": "Care Teams",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "resolve()",
"type": "type"
} ]
},
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "*",
"id": "Composition.section:sectionCareTeam.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "Care Team",
"isModifier": false,
"short": "Care Team",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/CareTeam" ]
} ],
"sliceName": "cteam",
"max": "*",
"id": "Composition.section:sectionCareTeam.entry:cteam",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionCareTeam.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"mustSupport": false,
"max": "0",
"id": "Composition.section:sectionCareTeam.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
}, {
"constraint": [ {
"key": "cmp-1",
"human": "A section must contain at least one of text, entries, or sub-sections",
"xpath": "exists(f:text) or exists(f:entry) or exists(f:section)",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "text.exists() or entry.exists() or section.exists()"
}, {
"key": "cmp-2",
"human": "A section can only have an emptyReason if it is empty",
"xpath": "not(exists(f:emptyReason) and exists(f:entry))",
"source": "http://hl7.org/fhir/StructureDefinition/Composition",
"severity": "error",
"expression": "emptyReason.empty() or entry.empty()"
}, {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section",
"min": 0,
"definition": "This section lists documents and attachments associated to this report",
"isModifier": false,
"short": "Attachments",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.structuredBody.component.section",
"identity": "cda"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"sliceName": "sectionAttachments",
"max": "1",
"id": "Composition.section:sectionAttachments",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section"
},
"isSummary": false
}, {
"path": "Composition.section.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Composition.section:sectionAttachments.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Composition.section:sectionAttachments.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Composition.section.modifierExtension",
"requirements": "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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Composition.section:sectionAttachments.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.title",
"requirements": "Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.",
"min": 1,
"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.",
"isModifier": false,
"short": "Label for section (e.g. for ToC)",
"mapping": [ {
"map": "./title",
"identity": "rim"
}, {
"map": ".title",
"identity": "cda"
} ],
"type": [ {
"code": "string"
} ],
"alias": [ "header", "label", "caption" ],
"max": "1",
"id": "Composition.section:sectionAttachments.title",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.title"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.code",
"requirements": "Provides computable standardized labels to topics within the document.",
"min": 1,
"definition": "A code identifying the kind of content contained within the section. This must be consistent with the section title.",
"isModifier": false,
"short": "Classification of section (recommended)",
"mapping": [ {
"map": "./code",
"identity": "rim"
}, {
"map": ".code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/doc-section-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CompositionSectionType"
} ],
"description": "Classification of a section of a composition/document."
},
"max": "1",
"id": "Composition.section:sectionAttachments.code",
"comment": "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. \n\nIf 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.",
"patternCodeableConcept": {
"coding": [ {
"code": "77599-9",
"system": "http://loinc.org"
} ]
},
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.code"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.author",
"requirements": "Identifies who is responsible for the content.",
"min": 0,
"definition": "Identifies who is responsible for the information in this section, not necessarily who typed it in.",
"isModifier": false,
"short": "Who and/or what authored the section",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": ".author.assignedAuthor",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "*",
"id": "Composition.section:sectionAttachments.author",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.author"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.focus",
"min": 0,
"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).",
"isModifier": false,
"short": "Who/what the section is about, when it is not about the subject of composition",
"mapping": [ {
"map": ".subject? (CDA did not differentiate between subject and focus)",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Composition.section:sectionAttachments.focus",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.focus"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the section, for human interpretation",
"mapping": [ {
"map": ".text",
"identity": "rim"
}, {
"map": ".text",
"identity": "cda"
} ],
"type": [ {
"code": "Narrative"
} ],
"max": "1",
"id": "Composition.section:sectionAttachments.text",
"condition": [ "cmp-1" ],
"comment": "Document profiles may define what content should be represented in the narrative to ensure clinical safety.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.mode",
"requirements": "Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.",
"min": 0,
"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.",
"isModifier": false,
"short": "working | snapshot | changes",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": ".outBoundRelationship[typeCode=COMP].target[classCode=OBS\"].value",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/list-mode|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionMode"
} ],
"description": "The processing mode that applies to this section."
},
"max": "1",
"id": "Composition.section:sectionAttachments.mode",
"comment": "This element is labeled as a modifier because a change list must not be misunderstood as a complete list.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.mode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.orderedBy",
"requirements": "Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.",
"min": 0,
"definition": "Specifies the order applied to the items in the section entries.",
"isModifier": false,
"short": "Order of section entries",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].sequenceNumber > 1",
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-order",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEntryOrder"
} ],
"description": "What order applies to the items in the entry."
},
"max": "1",
"id": "Composition.section:sectionAttachments.orderedBy",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.orderedBy"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.entry",
"min": 0,
"definition": "A reference to the actual resource from which the narrative in the section is derived.",
"isModifier": false,
"short": "A reference to data that supports this section",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]",
"identity": "rim"
}, {
"map": ".entry",
"identity": "cda"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DocumentReference", "http://hl7.org/fhir/StructureDefinition/Binary" ]
} ],
"max": "*",
"id": "Composition.section:sectionAttachments.entry",
"condition": [ "cmp-2" ],
"comment": "If there are no entries in the list, an emptyReason SHOULD be provided.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.entry"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.emptyReason",
"requirements": "Allows capturing things like \"none exist\" or \"not asked\" which can be important for most lists.",
"min": 0,
"definition": "If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.",
"isModifier": false,
"short": "Why the section is empty",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ,code,
"identity": "rim"
}, {
"map": "n/a",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/list-empty-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SectionEmptyReason"
} ],
"description": "If a section is empty, why it is empty."
},
"max": "1",
"id": "Composition.section:sectionAttachments.emptyReason",
"condition": [ "cmp-2" ],
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Composition.section.emptyReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "Composition.section.section",
"min": 0,
"definition": "A nested sub-section within this section.",
"isModifier": false,
"short": "Nested Section",
"mapping": [ {
"map": "./outboundRelationship[typeCode=\"COMP\" and isNormalActRelationship()]/target[moodCode=\"EVN\" and classCode=\"DOCSECT\" and isNormalAct]",
"identity": "rim"
}, {
"map": ".component.section",
"identity": "cda"
} ],
"contentReference": "http://hl7.org/fhir/StructureDefinition/Composition#Composition.section",
"max": "*",
"id": "Composition.section:sectionAttachments.section",
"condition": [ "cmp-1" ],
"comment": "Nested sections are primarily used to help human readers navigate to particular portions of the document.",
"base": {
"max": "*",
"min": 0,
"path": "Composition.section.section"
},
"isSummary": false
} ],
"extension": [ {
"url": "http://hl7.org/fhir/tools/StructureDefinition/snapshot-base-version",
"valueString": "4.0.1"
} ]
},
"status": "draft",
"id": "bba9a746-8d20-4187-9199-de900bce8c91",
"kind": "resource",
"url": "http://hl7.eu/fhir/hdr/StructureDefinition/composition-eu-hdr",
"version": "0.1.0-ballot",
"differential": {
"element": [ {
"id": "Composition",
"path": "Composition",
"short": "Hospital Discharge Report composition",
"constraint": [ {
"key": "text-or-section",
"human": "A Composition SHALL have either text, at least one section, or both.",
"source": "http://hl7.eu/fhir/hdr/StructureDefinition/composition-eu-hdr",
"severity": "error",
"expression": "text.exists() or section.exists()"
} ],
"definition": "Hospital Discharge Report 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.extension",
"path": "Composition.extension",
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "url",
"type": "value"
} ]
}
}, {
"id": "Composition.extension:basedOn",
"max": "*",
"min": 0,
"path": "Composition.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/StructureDefinition/event-basedOn" ]
} ],
"sliceName": "basedOn"
}, {
"id": "Composition.extension:basedOn.value[x]",
"path": "Composition.extension.value[x]",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource", "http://hl7.org/fhir/StructureDefinition/ServiceRequest" ]
} ]
}, {
"id": "Composition.extension:presentedForm",
"max": "*",
"min": 0,
"path": "Composition.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.eu/fhir/StructureDefinition/presentedForm" ]
} ],
"short": "Presented form",
"sliceName": "presentedForm"
}, {
"id": "Composition.extension:presentedForm.value[x].contentType",
"path": "Composition.extension.value[x].contentType",
"example": [ {
"label": "pdf",
"valueCode": "application/pdf"
} ]
}, {
"id": "Composition.extension:presentedForm.value[x].data",
"path": "Composition.extension.value[x].data",
"short": "B64 in-line data"
}, {
"id": "Composition.extension:presentedForm.value[x].url",
"path": "Composition.extension.value[x].url",
"short": "URL of the document"
}, {
"id": "Composition.extension:compositionVersionR5",
"max": "*",
"min": 0,
"path": "Composition.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version" ]
} ],
"sliceName": "compositionVersionR5"
}, {
"id": "Composition.extension:compositionVersionR5.value[x]",
"path": "Composition.extension.value[x]",
"short": "Business version"
}, {
"id": "Composition.extension:information-recipient",
"max": "*",
"min": 0,
"path": "Composition.extension",
"type": [ {
"code": "Extension",
"profile": [ "http://hl7.eu/fhir/StructureDefinition/information-recipient" ]
} ],
"sliceName": "information-recipient"
}, {
"id": "Composition.extension:information-recipient.value[x]",
"path": "Composition.extension.value[x]",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/base/StructureDefinition/practitionerRole-eu-core", "http://hl7.eu/fhir/base/StructureDefinition/practitioner-eu-core", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.eu/fhir/base/StructureDefinition/patient-eu-core", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.eu/fhir/base/StructureDefinition/organization-eu-core" ]
} ]
}, {
"id": "Composition.identifier",
"path": "Composition.identifier",
"short": "HDR business identifier"
}, {
"id": "Composition.status",
"path": "Composition.status",
"short": "HDR status"
}, {
"id": "Composition.type",
"path": "Composition.type",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"short": "Kind of composition (\"Hospital Discharge Report\")",
"definition": "Specifies that this composition refer to a Hospital Discharge Report",
"patternCodeableConcept": {
"coding": [ {
"code": "34105-7",
"system": "http://loinc.org",
"display": "Hospital Discharge summary"
} ]
}
}, {
"id": "Composition.subject",
"min": 1,
"path": "Composition.subject",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/base/StructureDefinition/patient-eu-core" ]
} ],
"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 hdr the subject is always the patient."
}, {
"id": "Composition.encounter",
"path": "Composition.encounter",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/encounter-eu-hdr" ]
} ]
}, {
"id": "Composition.date",
"path": "Composition.date",
"short": "HDR date"
}, {
"id": "Composition.author",
"path": "Composition.author",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/base/StructureDefinition/practitioner-eu-core", "http://hl7.eu/fhir/base/StructureDefinition/practitionerRole-eu-core", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.eu/fhir/base/StructureDefinition/organization-eu-core" ]
} ],
"short": "Who and/or what authored the Hospital Discharge Report",
"definition": "Identifies who is responsible for the information in the Hospital Discharge Report, not necessarily who typed it in."
}, {
"id": "Composition.title",
"path": "Composition.title",
"short": "Hospital Discharge Report",
"definition": "Official human-readable label for the composition.\r\n\r\nFor this document should be \"Hospital Discharge Report\" or any equivalent translation"
}, {
"id": "Composition.attester.mode",
"path": "Composition.attester.mode",
"short": "The type of attestation"
}, {
"id": "Composition.attester.time",
"path": "Composition.attester.time",
"short": "When the composition was attested."
}, {
"id": "Composition.attester.party",
"path": "Composition.attester.party",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/base/StructureDefinition/practitioner-eu-core", "http://hl7.eu/fhir/base/StructureDefinition/practitionerRole-eu-core", "http://hl7.eu/fhir/base/StructureDefinition/organization-eu-core" ]
} ],
"short": "Who attested the composition."
}, {
"id": "Composition.section",
"min": 1,
"path": "Composition.section",
"short": "Sections composing the Hospital Discharge Report",
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "code",
"type": "value"
} ]
},
"definition": "The root of the sections that make up the Hospital Discharge Report composition."
}, {
"id": "Composition.section:sectionAdmissionEvaluation",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Hospital Admission evaluation",
"comment": "Admission evaluation should be reported only exceptionally, if it is relevant to ensure continuity of care.",
"sliceName": "sectionAdmissionEvaluation",
"definition": "Hospital Admission evaluation"
}, {
"id": "Composition.section:sectionAdmissionEvaluation.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionAdmissionEvaluation.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "67851-6",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionAnthropometry",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Anthropometric observations",
"sliceName": "sectionAnthropometry",
"definition": "Anthropometric Observations sub-section"
}, {
"id": "Composition.section:sectionAnthropometry.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionAnthropometry.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "anthropometry",
"system": "http://hl7.eu/fhir/hdr/CodeSystem/temporarySystem-hdr-eu"
} ]
}
}, {
"id": "Composition.section:sectionAnthropometry.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/DocumentReference", "http://hl7.org/fhir/StructureDefinition/vitalsigns" ]
} ]
}, {
"id": "Composition.section:sectionVitalSigns",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Vital signs",
"sliceName": "sectionVitalSigns",
"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"
}, {
"id": "Composition.section:sectionVitalSigns.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionVitalSigns.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "8716-3",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionVitalSigns.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/DocumentReference", "http://hl7.org/fhir/StructureDefinition/vitalsigns" ]
} ]
}, {
"id": "Composition.section:sectionPhysicalFindings",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Physical findings",
"sliceName": "sectionPhysicalFindings",
"definition": "Physical findings"
}, {
"id": "Composition.section:sectionPhysicalFindings.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionPhysicalFindings.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "29545-1",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionFunctionalStatus",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Functional status",
"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.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionFunctionalStatus.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "47420-5",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionFunctionalStatus.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Condition", "http://hl7.org/fhir/StructureDefinition/ClinicalImpression", "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/DocumentReference", "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse" ]
} ],
"short": "Optional entry used to represent disabilities and functional assessments",
"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."
}, {
"id": "Composition.section:sectionHospitalCourse",
"max": "1",
"min": 1,
"path": "Composition.section",
"short": "Significant information about course of hospital stay",
"sliceName": "sectionHospitalCourse",
"definition": "This section includes basic information about hospital staty (encounter), diagnostic summary in narrative form, pharmacotherapy, major procedures, medical devices, significant findings during hospital stay and clinical synthesis."
}, {
"id": "Composition.section:sectionHospitalCourse.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionHospitalCourse.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "8648-8",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionDiagnosticSummary",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Problem specification in narrative form",
"sliceName": "sectionDiagnosticSummary",
"definition": "All problems/diagnoses that affect care during the inpatient case or are important to be recorded to ensure continuity of care. The diagnostic summary differentiates, in accordance with the international recommendation, between problems treated during hospital stay and other (untreated) problems. Treated problems are problems that were the subject of diagnostics, therapy, nursing, or (continuous) monitoring during the hospitalisation. Furthermore problems could be divided into three categories: problems present on admission (POA), conditions acquired during hospital stay (HAC) and problems that cannot be classified as being of any of the two (N/A). The diagnostic summary contains all conditions as they were recognised at the end of hospitalisation, after all examinations. This section contains concise, well specified, codeable, summary of problems. Problems are ordered by importance (main problems first) during hospital stay. Description of the problem might be completed with additional details in the medical history section and/or in the Synthesis section."
}, {
"id": "Composition.section:sectionDiagnosticSummary.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionDiagnosticSummary.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "11535-2",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionDiagnosticSummary.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/condition-eu-hdr" ]
} ]
}, {
"id": "Composition.section:sectionSignificantProcedures",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Significant procedures",
"sliceName": "sectionSignificantProcedures",
"definition": "Significant surgical and non-surgical procedures performed during hospitalisation which are significant for continuity of care, e.g. surgeries and other \"instrumental\"interventions (endoscopic, intravascular), chemotherapy, radiotherapy, purification methods (dialysis, hemoperfusion), circulation support methods (counterpulsation, etc.), administration of blood derivatives or others.\r\nThis section does not include purely diagnostic procedures (MRI, CT, etc.). If no significant performance has been performed, this fact must be explicitly stated using the IPS Absent and Unknown Data."
}, {
"id": "Composition.section:sectionSignificantProcedures.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionSignificantProcedures.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "10185-7",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionSignificantProcedures.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/procedure-eu-hdr" ]
} ]
}, {
"id": "Composition.section:sectionSignificantProcedures.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionMedicalDevices",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Medical devices and implants",
"sliceName": "sectionMedicalDevices",
"definition": "Implants and used medical devices that affected or may affect the provision of health services (diagnosis and treatment). Also medical devices explanted, or its use was stopped during hospitalisation. If the section is blank, the reason must be explicitly stated using the IPS Absent and Unknown Data coding system."
}, {
"id": "Composition.section:sectionMedicalDevices.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionMedicalDevices.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "57080-4",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionMedicalDevices.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/deviceUseStatement-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/procedure-eu-hdr" ]
} ]
}, {
"id": "Composition.section:sectionMedicalDevices.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionPharmacotherapy",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Pharmacotherapy",
"sliceName": "sectionPharmacotherapy",
"definition": "Selected drug treatment during hospitalisation. Medicinal products that were administered during hospitalisation and whose administration has already been discontinued before discharge. Only products which are important for continuity of care (antibiotics other than completely routine, corticosteroids in high doses, etc.) will be listed. Products which administration will continue after discharge will be also recorder in the Medication summary section.\r\nMedicinal products, the administration of which was started during hospitalisation but is also recommended after discharge, will be listed in the summary table in the recommendation section."
}, {
"id": "Composition.section:sectionPharmacotherapy.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionPharmacotherapy.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "87232-5",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionPharmacotherapy.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/medicationStatement-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/medicationRequest-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/medicationDispense-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/medicationAdministration-eu-hdr" ]
} ]
}, {
"id": "Composition.section:sectionSignificantResults",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Significant Observation Results",
"sliceName": "sectionSignificantResults",
"definition": "Results of significant functional, diagnostic, and imaging examinations to ensure continuity of care, performed during hospitalisation. Results of examinations ordered but not yet delivered should be presented separately from results already delivered."
}, {
"id": "Composition.section:sectionSignificantResults.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionSignificantResults.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "30954-2",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionSignificantResults.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/DiagnosticReport", "http://hl7.org/fhir/StructureDefinition/DocumentReference" ]
} ],
"short": "significant results",
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
},
"definition": "significant results"
}, {
"id": "Composition.section:sectionSignificantResults.entry:labResult",
"max": "*",
"min": 0,
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/laboratory/StructureDefinition/Observation-resultslab-eu-lab" ]
} ],
"short": "Laboratory Result",
"sliceName": "labResult",
"definition": "Laboratory Result"
}, {
"id": "Composition.section:sectionSignificantResults.entry:radResult",
"max": "*",
"min": 0,
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/observation-imgFinding-eu-hdr" ]
} ],
"short": "Radiology Result",
"sliceName": "radResult",
"definition": "Radiology Result"
}, {
"id": "Composition.section:sectionSynthesis",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Synthesis",
"sliceName": "sectionSynthesis",
"definition": "This section provides clinical synthesis (e.g. description of reasons and course of hospital stay) clustered by managed conditions. Clinical synthesis may include clinical reasoning (differential diagnostics, explanation of clinical context) in clinically complex conditions."
}, {
"id": "Composition.section:sectionSynthesis.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionSynthesis.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "67781-5",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionPlanOfCare",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Plan of Care 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.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionPlanOfCare.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "18776-5",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionPlanOfCare.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/carePlan-eu-hdr", "http://hl7.org/fhir/StructureDefinition/DocumentReference" ]
} ]
}, {
"id": "Composition.section:sectionDischargeInstructions",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Hospital Discharge Instructions",
"sliceName": "sectionDischargeInstructions",
"definition": "Hospital Discharge Instructions"
}, {
"id": "Composition.section:sectionDischargeInstructions.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionDischargeInstructions.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "8653-8",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionDischargeMedications",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Hospital discharge medications",
"sliceName": "sectionDischargeMedications",
"definition": "Hospital discharge medications defines the medications that the patient is intended to take, or stop, after discharge"
}, {
"id": "Composition.section:sectionDischargeMedications.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionDischargeMedications.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "75311-1",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionDischargeMedications.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/medicationRequest-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/medicationDispense-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/medicationStatement-eu-hdr" ]
} ]
}, {
"id": "Composition.section:sectionAllergies",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Allergies and Intolerances Section",
"sliceName": "sectionAllergies",
"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."
}, {
"id": "Composition.section:sectionAllergies.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionAllergies.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "48765-2",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionAllergies.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/allergyIntolerance-eu-hdr", "http://hl7.org/fhir/StructureDefinition/DocumentReference" ]
} ],
"short": "Relevant allergies or intolerances (conditions) for that patient.",
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "resolve()",
"type": "type"
} ]
},
"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.\r\n This entry shall be used to document that no information about allergies is available, or that no allergies are known ."
}, {
"id": "Composition.section:sectionAllergies.entry:allergyIntolerance",
"max": "*",
"min": 0,
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/allergyIntolerance-eu-hdr" ]
} ],
"short": "Allergy entry",
"sliceName": "allergyIntolerance",
"definition": "Allergy entry"
}, {
"id": "Composition.section:sectionAlert",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Alert Section",
"sliceName": "sectionAlert",
"definition": "// SHORT\r\n A warning, other than included in allergies.\r\n The warning can be entered in code there are codes for frequently used alerts but seeing the dynamic nature of the warnings, these alerts will often be entered as free text.\r\n Any clinical information that is imperative to know so that the life or health of the patient does not come under threat. \r\n Example 1: the patient has a rare disease that requires special treatment \r\n Example 2: Airway Alert / Difficult Intubation\r\n Example 3: Diagnoses such as malignant hyperthermia, porphyria, and bleeding disorders; special treatments like anticoagulants or immunosuppressants; implanted devices. \r\n Example 4: transplanted organs illustrate other information that has to be taken into account in a healthcare contact. \r\n Example 5: participation in a clinical trial that has to be taken into account in a healthcare contact."
}, {
"id": "Composition.section:sectionAlert.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionAlert.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "104605-1",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionAlert.entry",
"path": "Composition.section.entry",
"short": "Alerts",
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "resolve()",
"type": "type"
} ]
},
"definition": "Alerts"
}, {
"id": "Composition.section:sectionAlert.entry:flag",
"max": "*",
"min": 0,
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Flag" ]
} ],
"short": "Flags",
"sliceName": "flag",
"definition": "Flags"
}, {
"id": "Composition.section:sectionPayers",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Health insurance and payment information.",
"sliceName": "sectionPayers",
"definition": "This section includes heath insurance and payment information."
}, {
"id": "Composition.section:sectionPayers.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionPayers.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "48768-6",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionPayers.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Coverage" ]
} ]
}, {
"id": "Composition.section:sectionPatientHx",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Patient history Section",
"sliceName": "sectionPatientHx",
"definition": "This Section describes all aspects of the medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. The history may be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections including Past Medical History, Social History."
}, {
"id": "Composition.section:sectionPatientHx.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionPatientHx.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "35090-0",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionProblemList",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Problem List Section",
"sliceName": "sectionProblemList",
"definition": "The IPS derived problem section lists and describes clinical problems or conditions currently being monitored for the patient."
}, {
"id": "Composition.section:sectionProblemList.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionProblemList.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "11450-4",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionProblemList.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/condition-eu-hdr" ]
} ],
"short": "Conditions the patient suffered in the past.",
"definition": "It contains a description of the conditions the patient suffered in the past."
}, {
"id": "Composition.section:sectionPastIllnessHx",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "History of Past Illness Section",
"sliceName": "sectionPastIllnessHx",
"definition": "The History of Past Illness section contains a narrative description and coded entries of the conditions the patient suffered in the past"
}, {
"id": "Composition.section:sectionPastIllnessHx.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionPastIllnessHx.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "11348-0",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionPastIllnessHx.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/condition-eu-hdr" ]
} ],
"short": "Conditions the patient suffered in the past.",
"definition": "It contains a description of the conditions the patient suffered in the past."
}, {
"id": "Composition.section:sectionHistoryMedicalDevices",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "History of Medical devices and implants",
"sliceName": "sectionHistoryMedicalDevices",
"definition": "The medical devices section contains narrative text and coded entries describing the patient history of medical device use."
}, {
"id": "Composition.section:sectionHistoryMedicalDevices.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionHistoryMedicalDevices.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "46264-8",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionHistoryMedicalDevices.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/deviceUseStatement-eu-hdr", "http://hl7.eu/fhir/hdr/StructureDefinition/procedure-eu-hdr" ]
} ]
}, {
"id": "Composition.section:sectionHistoryMedicalDevices.section",
"max": "0",
"path": "Composition.section.section"
}, {
"id": "Composition.section:sectionProceduresHx",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "History of Procedures 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.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionProceduresHx.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "47519-4",
"system": "http://loinc.org",
"display": "History of Procedures Document"
} ]
}
}, {
"id": "Composition.section:sectionProceduresHx.entry",
"path": "Composition.section.entry",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.eu/fhir/hdr/StructureDefinition/procedure-eu-hdr" ]
} ],
"short": "Patient past procedures pertinent to the scope of this document.",
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "resolve()",
"type": "type"
} ]
},
"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. This entry shall be used to document that no information about past procedures is available, or that no relevant past procedures are known."
}, {
"id": "Composition.section:sectionImmunizations",
"max": "1",
"min": 0,
"path": "Composition.section",
"short": "Immunizations 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 current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized."
}, {
"id": "Composition.section:sectionImmunizations.title",
"min": 1,
"path": "Composition.section.title"
}, {
"id": "Composition.section:sectionImmunizations.code",
"min": 1,
"path": "Composition.section.code",
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips" ]
} ],
"patternCodeableConcept": {
"coding": [ {
"code": "11369-6",
"system": "http://loinc.org"
} ]
}
}, {
"id": "Composition.section:sectionImmunizations.entry",
"path": "Composition.section.entry",
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