description: Clinical document used to represent the International Patient Summary (IPS) data set. \r\nAn International Patient Summary (IPS) document is an electronic health record extract containing essential healthcare information about a subject of care. \r\nThe IPS dataset is minimal and non-exhaustive; specialty-agnostic and condition-independent; but still clinically relevant. As specified in EN 17269 and ISO/DIS 27269, it is designed for supporting the use case scenario for ‘unplanned, cross border care’, but it is not limited to it. It is intended to be international, i.e., to provide generic solutions for global application beyond a particular region or country.\r\n\r\nThis profile is based on the ClinicalDocument profile. package_name: hl7.fhir.uv.ips derivation: constraint name: CompositionUvIps type: Composition elements: date: {mustSupport: true, index: 7} encounter: {mustSupport: true, index: 6} section: short: Sections composing the IPS mustSupport: true index: 26 slicing: rules: open ordered: false discriminator: - {path: code, type: pattern} min: 1 slices: sectionProblems: match: code: coding: - {code: 11450-4, system: 'http://loinc.org'} schema: short: IPS Problems Section mustSupport: true _required: true index: 43 elements: title: {mustSupport: true, index: 44} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 11450-4, system: 'http://loinc.org'} index: 45 text: {type: Narrative, mustSupport: true, index: 46} entry: short: Clinical problems or conditions currently being monitored for the patient. mustSupport: true index: 47 slicing: rules: open discriminator: - {path: $this.resolve(), type: profile} min: 1 slices: problem: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/Condition-uv-ips'] _required: true index: 48 min: 1 emptyReason: {mustSupport: false, index: 49} section: {mustSupport: false, index: 50} required: [entry, text, title, code] sectionProceduresHx: match: code: coding: - {code: 47519-4, system: 'http://loinc.org'} schema: short: IPS History of Procedures Section mustSupport: true index: 51 elements: title: {mustSupport: true, index: 52} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 47519-4, system: 'http://loinc.org'} index: 53 text: {type: Narrative, mustSupport: true, index: 54} entry: short: Patient past procedures pertinent to the scope of this document. mustSupport: true index: 55 slicing: rules: open discriminator: - {path: $this.resolve(), type: profile} min: 1 slices: procedure: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/Procedure-uv-ips'] _required: true index: 56 min: 1 emptyReason: {mustSupport: false, index: 57} section: {mustSupport: false, index: 58} required: [entry, text, title, code] sectionPlanOfCare: match: code: coding: - {code: 18776-5, system: 'http://loinc.org'} schema: short: IPS Plan of Care Section mustSupport: true index: 109 elements: title: {mustSupport: true, index: 110} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 18776-5, system: 'http://loinc.org'} index: 111 text: {type: Narrative, mustSupport: true, index: 112} entry: short: Optional entry used to represent structured care plans mustSupport: false index: 113 slicing: rules: open discriminator: - {path: $this.resolve(), type: profile} min: null slices: carePlan: match: {} schema: type: Reference mustSupport: false refers: ['http://hl7.org/fhir/StructureDefinition/CarePlan'] index: 114 emptyReason: {mustSupport: false, index: 115} section: {mustSupport: false, index: 116} required: [text, title, code] sectionMedicalDevices: match: code: coding: - {code: 46264-8, system: 'http://loinc.org'} schema: short: IPS Medical Devices Section mustSupport: true index: 67 elements: title: {mustSupport: true, index: 68} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 46264-8, system: 'http://loinc.org'} index: 69 text: {type: Narrative, mustSupport: true, index: 70} entry: short: Patient history of medical device use. mustSupport: true index: 71 slicing: rules: open discriminator: - {path: $this.resolve(), type: profile} min: 1 slices: deviceStatement: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/DeviceUseStatement-uv-ips'] _required: true index: 72 min: 1 emptyReason: {mustSupport: false, index: 73} section: {mustSupport: false, index: 74} required: [entry, text, title, code] sectionSocialHistory: match: code: coding: - {code: 29762-2, system: 'http://loinc.org'} schema: short: IPS Social History Section mustSupport: true index: 117 elements: title: {mustSupport: true, index: 118} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 29762-2, system: 'http://loinc.org'} index: 119 text: {mustSupport: true, index: 120} entry: short: Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) mustSupport: true index: 121 slicing: rules: open discriminator: - {path: $this.resolve(), type: profile} min: null slices: smokingTobaccoUse: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-tobaccouse-uv-ips'] index: 122 max: 1 alcoholUse: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-alcoholuse-uv-ips'] index: 123 max: 1 emptyReason: {mustSupport: false, index: 124} section: {mustSupport: false, index: 125} required: [text, title, code] sectionFunctionalStatus: match: code: coding: - {code: 47420-5, system: 'http://loinc.org'} schema: short: IPS Functional Status mustSupport: true index: 100 elements: title: {mustSupport: true, index: 101} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 47420-5, system: 'http://loinc.org'} index: 102 text: {type: Narrative, mustSupport: true, index: 103} entry: short: Optional entry used to represent disabilities and functional assessments mustSupport: true index: 104 slicing: rules: open discriminator: - {path: $this.resolve(), type: profile} min: null slices: disability: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/Condition-uv-ips'] index: 105 functionalAssessment: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/ClinicalImpression'] index: 106 emptyReason: {mustSupport: false, index: 107} section: {mustSupport: false, index: 108} required: [text, title, code] sectionAllergies: match: code: coding: - {code: 48765-2, system: 'http://loinc.org'} schema: short: IPS Allergies and Intolerances Section mustSupport: true _required: true index: 35 elements: title: {mustSupport: true, index: 36} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 48765-2, system: 'http://loinc.org'} index: 37 text: {type: Narrative, mustSupport: true, index: 38} entry: short: Relevant allergies or intolerances (conditions) for that patient. mustSupport: true index: 39 slicing: rules: open discriminator: - {path: $this.resolve(), type: profile} min: 1 slices: allergyOrIntolerance: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/AllergyIntolerance-uv-ips'] _required: true index: 40 min: 1 emptyReason: {mustSupport: false, index: 41} section: {mustSupport: false, index: 42} required: [entry, text, title, code] sectionPregnancyHx: match: code: coding: - {code: 10162-6, system: 'http://loinc.org'} schema: short: IPS History of Pregnancy Section mustSupport: true index: 126 elements: title: {mustSupport: true, index: 127} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 10162-6, system: 'http://loinc.org'} index: 128 text: {mustSupport: true, index: 129} entry: short: Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. mustSupport: true index: 130 slicing: rules: open discriminator: - {path: $this.resolve(), type: profile} min: null slices: pregnancyStatus: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-pregnancy-status-uv-ips'] index: 131 pregnancyOutcomeSummary: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-pregnancy-outcome-uv-ips'] index: 132 emptyReason: {mustSupport: false, index: 133} section: {mustSupport: false, index: 134} required: [text, title, code] sectionAdvanceDirectives: match: code: coding: - {code: 42348-3, system: 'http://loinc.org'} schema: short: IPS Advance Directives Section mustSupport: true index: 135 elements: title: {mustSupport: true, index: 136} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 42348-3, system: 'http://loinc.org'} index: 137 text: {type: Narrative, mustSupport: true, index: 138} entry: short: Narrative description of the patient's advance directive. mustSupport: true index: 139 slicing: rules: open discriminator: - {path: $this.resolve(), type: profile} min: null slices: advanceDirectivesConsent: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/Consent'] index: 140 emptyReason: {mustSupport: false, index: 141} section: {mustSupport: false, index: 142} required: [text, title, code] sectionVitalSigns: match: code: coding: - {code: 8716-3, system: 'http://loinc.org'} schema: short: IPS Vital Signs Section mustSupport: true label: Vital signs index: 84 elements: title: {mustSupport: true, index: 85} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 8716-3, system: 'http://loinc.org'} index: 86 text: {type: Narrative, mustSupport: true, index: 87} entry: short: Notable vital signs or physical findings. mustSupport: true index: 88 slicing: rules: open discriminator: - {path: $this.resolve(), type: profile} min: null slices: vitalSign: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/vitalsigns'] index: 89 emptyReason: {mustSupport: false, index: 90} section: {mustSupport: false, index: 91} required: [text, title, code] sectionImmunizations: match: code: coding: - {code: 11369-6, system: 'http://loinc.org'} schema: short: IPS Immunizations Section mustSupport: true index: 59 elements: title: {mustSupport: true, index: 60} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 11369-6, system: 'http://loinc.org'} index: 61 text: {type: Narrative, mustSupport: true, index: 62} entry: short: Patient's immunization status and pertinent history. mustSupport: true index: 63 slicing: rules: open discriminator: - {path: $this.resolve(), type: profile} min: 1 slices: immunization: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/Immunization-uv-ips'] _required: true index: 64 min: 1 emptyReason: {mustSupport: false, index: 65} section: {mustSupport: false, index: 66} required: [entry, text, title, code] sectionResults: match: code: coding: - {code: 30954-2, system: 'http://loinc.org'} schema: short: IPS Results Section mustSupport: true index: 75 elements: title: {mustSupport: true, index: 76} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 30954-2, system: 'http://loinc.org'} index: 77 text: {mustSupport: true, index: 78} entry: short: Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. mustSupport: true index: 79 slicing: rules: open discriminator: - {path: $this.resolve(), type: type} - {path: $this.resolve(), type: profile} min: 1 slices: results-observation: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-results-laboratory-uv-ips', 'http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-results-pathology-uv-ips', 'http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-results-radiology-uv-ips', 'http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-results-uv-ips'] index: 80 results-diagnosticReport: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/DiagnosticReport-uv-ips'] index: 81 emptyReason: {mustSupport: false, index: 82} section: {mustSupport: false, index: 83} required: [entry, text, title, code] sectionMedications: match: code: coding: - {code: 10160-0, system: 'http://loinc.org'} schema: short: IPS Medication Summary Section mustSupport: true _required: true index: 27 elements: title: {short: Medication Summary section, mustSupport: true, index: 28} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 10160-0, system: 'http://loinc.org'} index: 29 text: {type: Narrative, mustSupport: true, index: 30} entry: short: Medications relevant for the scope of the patient summary mustSupport: true index: 31 slicing: rules: open discriminator: - {path: $this.resolve(), type: profile} min: 1 slices: medicationStatement: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/MedicationStatement-uv-ips'] _required: true index: 32 min: 1 emptyReason: {mustSupport: false, index: 33} section: {mustSupport: false, index: 34} required: [entry, text, title, code] sectionPastIllnessHx: match: code: coding: - {code: 11348-0, system: 'http://loinc.org'} schema: short: IPS History of Past Illness Section mustSupport: true index: 92 elements: title: {mustSupport: true, index: 93} code: type: CodeableConcept mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 11348-0, system: 'http://loinc.org'} index: 94 text: {mustSupport: true, index: 95} entry: short: Conditions the patient suffered in the past. mustSupport: true index: 96 slicing: rules: open discriminator: - {path: $this.resolve(), type: profile} min: 1 slices: pastProblem: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/Condition-uv-ips'] _required: true index: 97 min: 1 emptyReason: {mustSupport: false, index: 98} section: {mustSupport: false, index: 99} required: [entry, text, title, code] attester: mustSupport: true index: 11 elements: mode: {mustSupport: true, index: 12} time: {mustSupport: true, index: 13} party: {mustSupport: true, index: 14} type: type: CodeableConcept short: Kind of composition ("Patient Summary") mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 60591-5, system: 'http://loinc.org'} index: 3 title: {short: International Patient Summary, mustSupport: true, index: 9} author: {short: Who and/or what authored the IPS, mustSupport: true, index: 8} event: mustSupport: true index: 22 slicing: rules: open discriminator: - {path: code, type: pattern} min: null slices: careProvisioningEvent: match: code: coding: - {code: PCPR, system: 'http://terminology.hl7.org/CodeSystem/v3-ActClass'} schema: short: The care provisioning being documented mustSupport: true index: 23 elements: code: mustSupport: true pattern: type: CodeableConcept value: coding: - {code: PCPR, system: 'http://terminology.hl7.org/CodeSystem/v3-ActClass'} index: 24 period: {mustSupport: true, index: 25} required: [code] custodian: {mustSupport: true, index: 15} status: {mustSupport: true, index: 2} identifier: {mustSupport: true, index: 1} relatesTo: mustSupport: true index: 16 elements: code: {mustSupport: true, index: 17} target: mustSupport: true choices: [targetIdentifier, targetReference] index: 19 targetIdentifier: {type: Identifier, mustSupport: true, choiceOf: target, index: 20} targetReference: type: Reference mustSupport: true choiceOf: target refers: ['http://hl7.org/fhir/StructureDefinition/Composition', 'http://hl7.org/fhir/uv/ips/StructureDefinition/Composition-uv-ips'] index: 21 subject: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/uv/ips/StructureDefinition/Patient-uv-ips'] index: 4 elements: reference: {mustSupport: true, index: 5} required: [reference] confidentiality: {mustSupport: true, index: 10} text: {mustSupport: true, index: 0} package_version: 1.0.0 class: profile kind: resource url: http://hl7.org/fhir/uv/ips/StructureDefinition/Composition-uv-ips base: http://hl7.org/fhir/StructureDefinition/clinicaldocument version: 1.0.0 required: [section]