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SD.41 StructureDefinition-Composition-uv-ips
Composition International Patient Summary
The following picture provides an onverview of the IPS Composition content
A complete list of the sections, with description and used profiles is available in the International Patient Summary Structure page.
SD.41.1 Formal Views of Profile Content
Description of Profiles, Differentials, and Snapshots.
The official URL for this profile is: http://hl7.eu/fhir/trillium2/StructureDefinition/Composition-uv-ips
Published on Mon Mar 11 00:00:00 CET 2019 as a draft by Trillium2 Project.
This profile builds on Clinical Document Profile for Composition
Summary
Mandatory: 23 elements (45 nested mandatory elements)
Must-Support: 126 elements
Fixed Value: 18 elements
Prohibited: 30 elements
Structures
This structure refers to these other structures:
- http://hl7.org/fhir/uv/ips/StructureDefinition/Coding-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Patient-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Encounter-uv-trillium2
- http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/MedicationStatement-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/AllergyIntolerance-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Condition-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Procedure-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Immunization-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/DeviceUseStatement-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-laboratory-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-imaging-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-pathology-uv-ips
- http://hl7.org/fhir/StructureDefinition/vitalsigns
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-tobaccouse-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-alcoholuse-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-pregnancy-status-uv-ips
- http://hl7.eu/fhir/trillium2/StructureDefinition/Observation-pregnancy-outcome-uv-ips
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
- The element Composition.event is sliced based on the value of value:code
- The element Composition.section is sliced based on the value of value:code
- The element Composition.section.entry is sliced based on the value of profile:resolve() (Open at End)
Differential View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | S | 0..* | International Patient Summary composition | |
id | S | 0..1 | id | |
meta | S | 0..1 | Meta | |
text | S | 0..1 | Narrative | |
participant-uv-ips | 0..* | Reference(PractitionerRole | Organization) | Provider to be contacted URL: http://hl7.eu/fhir/trillium2/StructureDefinition/participant-uv-ips | |
identifier | S | 0..1 | Identifier | |
status | S | 1..1 | code | |
type | S | 1..1 | CodeableConcept | Kind of composition ("Patient Summary") |
coding | S | 1..* | CodingIPS | Code identifying the Patient Summary |
system | S | 1..1 | uri | Fixed Value: http://loinc.org |
code | S | 1..1 | code | Fixed Value: 60591-5 |
subject | S | 1..1 | Reference(Patient (Trillium II)) | |
reference | S | 1..1 | string | |
encounter | S | 0..1 | Reference(Encounter (Trillium II)) | |
reference | S | 1..1 | string | |
date | S | 1..1 | dateTime | |
author | S | 1..* | Reference(Practitioner | Device | Patient | RelatedPerson) | Who and/or what authored the IPS |
reference | S | 0..1 | string | |
title | S | 1..1 | string | International Patient Summary |
confidentiality | S | 0..1 | code | |
attester | S | 0..* | BackboneElement | |
mode | S | 1..* | code | |
time | S | 0..1 | dateTime | |
party | S | 0..1 | Reference(Patient | Practitioner | Organization) | |
reference | S | 0..1 | string | |
custodian | S | 0..1 | Reference(Organization) | |
reference | S | 0..1 | string | |
relatesTo | S | 0..* | BackboneElement | |
code | S | 1..1 | code | |
target[x] | S | 1..1 | Identifier, Reference(Composition | Trillium II IPS) | |
event | S | BackboneElement | Slice: Unordered, Open by value:code | |
event | S | 0..1 | BackboneElement | The care provisioning being documented |
code | S | 1..* | CodeableConcept | Fixed Value: {"coding":[{"system":"http://terminology.hl7.org/CodeSystem/v3-ActClass","code":"PCPR"}]} |
period | S | 0..1 | Period | |
section | S | BackboneElement | Sections composing the IPS Slice: Unordered, Open by value:code | |
section | S | 1..1 | BackboneElement | IPS Medication Summary Section |
title | S | 1..1 | string | Medication Summary section |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]} (History of Medication use Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Medications relevant for the scope of the patient summary Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Medication Statement (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 1..1 | BackboneElement | IPS Allergies and Intolerances Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]} (Allergies and adverse reactions Document) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Allergy Intolerance (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 1..1 | BackboneElement | IPS Problems Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]} (Problem list - Reported) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Condition (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS History of Procedures Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"47519-4"}]} (History of Procedures Document) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Procedure (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS Immunizations Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"11369-6"}]} (History of Immunization Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Patient's immunization status and pertinent history. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Immunization (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS Medical Devices Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"46264-8"}]} (History of medical device use) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Patient history of medical device use. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Device Use Statement (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS Results Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]} (Relevant diagnostic tests/laboratory data Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..* | Reference(Observation (Results: generic)) | |
entry | S | 0..* | Reference(Observation (Results: laboratory)) | |
entry | S | 0..* | Reference(Observation (Results: imaging)) | |
entry | S | 0..* | Reference(Observation (Results: pathology)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS Vital Signs Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]} (Vital signs) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Notable vital signs or physical findings. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..* | Reference(VitalSigns) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS History of Past Illness Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"11348-0"}]} (History of Past illness Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Conditions the patient suffered in the past. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 1..* | Reference(Condition (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS Functional Status |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"47420-5"}]} (Functional status assessment note) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Optional entry used to represent disabilities and functional assessments Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..* | Reference(Condition (Trillium II)) | |
entry | S | 0..* | Reference(ClinicalImpression) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS Plan of Care Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]} (Plan of care note) |
text | S | 1..1 | Narrative | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS Social History Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"29762-2"}]} (Social history Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..1 | Reference(Observation (SH: tobacco use)) | |
entry | S | 0..1 | Reference(Observation (SH: alcohol use)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS History of Pregnancy Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"10162-6"}]} (History of pregnancies Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..* | Reference(Observation (Pregnancy: status)) | |
entry | S | 0..* | Reference(Observation (Pregnancy: outcome)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | IPS Advance Directives Section |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConceptIPS | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"42348-3"}]} (Advance directives) |
text | S | 1..1 | Narrative | |
entry | S | 0..* | Reference(Resource | Consent) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
section | S | 0..1 | BackboneElement | Encounters sections |
title | S | 1..1 | string | |
code | S | 1..1 | CodeableConcept | Fixed Value: {"coding":[{"system":"http://loinc.org","code":"46240-8"}]} (History of Hospitalizations+Outpatient visits Narrative) |
text | S | 1..1 | Narrative | |
entry | S | Reference(Resource) | Slice: Unordered, Open At End by profile:resolve() | |
entry | S | 0..* | Reference(Encounter (Trillium II)) | |
emptyReason | 0..0 | |||
section | 0..0 | |||
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | SI | 0..* | International Patient Summary composition | |
id | SΣ | 0..1 | id | Logical id of this artifact |
meta | SΣ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: Common Languages (extensible) Max Binding: All Languages | |
text | SI | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
participant-uv-ips | I | 0..* | Reference(PractitionerRole | Organization) | Provider to be contacted URL: http://hl7.eu/fhir/trillium2/StructureDefinition/participant-uv-ips |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | SΣ | 0..1 | Identifier | Logical identifier of composition (version-independent) |
status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required) |
type | SΣ | 1..1 | CodeableConcept | Kind of composition ("Patient Summary") Binding: FHIR Document Type Codes (preferred) |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
coding | SI | 1..* | CodingIPS | Code identifying the Patient Summary |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
system | SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
version | SΣ | 0..1 | string | Version of the system - if relevant |
code | SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 60591-5 |
display | SΣ | 0..1 | string | Representation defined by the system |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
translation | SI | 0..* | (Complex) | Language Translation (Localization) URL: http://hl7.org/fhir/StructureDefinition/translation |
value | 0..1 | Primitive value for string Max Length: 1048576 | ||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
text | Σ | 0..1 | string | Plain text representation of the concept |
class | Σ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
subject | SΣ | 1..1 | Reference(Patient (Trillium II)) | Who and/or what the composition is about |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
reference | SΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
display | Σ | 0..1 | string | Text alternative for the resource |
encounter | SΣ | 0..1 | Reference(Encounter (Trillium II)) | Context of the Composition |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
reference | SΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
display | Σ | 0..1 | string | Text alternative for the resource |
date | SΣ | 1..1 | dateTime | Composition editing time |
author | SΣ | 1..* | Reference(Practitioner | Device | Patient | RelatedPerson) | Who and/or what authored the IPS |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
reference | SΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
display | Σ | 0..1 | string | Text alternative for the resource |
title | SΣ | 1..1 | string | International Patient Summary |
confidentiality | ?!SΣ | 0..1 | code | As defined by affinity domain Binding: ConfidentialityClassification (required) |
attester | SΣI | 0..* | BackboneElement | Attests to accuracy of composition |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
mode | SΣ | 1..* | code | personal | professional | legal | official Binding: CompositionAttestationMode (required) |
time | SΣ | 0..1 | dateTime | When the composition was attested |
party | SΣ | 0..1 | Reference(Patient | Practitioner | Organization) | Who attested the composition |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
reference | SΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
display | Σ | 0..1 | string | Text alternative for the resource |
custodian | SΣ | 0..1 | Reference(Organization) | Organization which maintains the composition |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
reference | SΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
display | Σ | 0..1 | string | Text alternative for the resource |
relatesTo | SΣI | 0..* | BackboneElement | Relationships to other compositions/documents |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
code | SΣ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required) |
target[x] | SΣ | 1..1 | Identifier, Reference(Composition | Trillium II IPS) | Target of the relationship |
event | SΣI | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: ActCode (example) |
period | Σ | 0..1 | Period | The period covered by the documentation |
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
event | SΣI | 0..1 | BackboneElement | The care provisioning being documented |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
code | SΣ | 1..* | CodeableConcept | Code(s) that apply to the event being documented Binding: ActCode (example) Fixed Value: {"coding":[{"system":"http://terminology.hl7.org/CodeSystem/v3-ActClass","code":"PCPR"}]} |
period | SΣ | 0..1 | Period | The period covered by the documentation |
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented |
section | SI | BackboneElement | Sections composing the IPS Slice: Unordered, Open by value:code | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | 0..1 | string | Label for section (e.g. for ToC) | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Document Section Codes (example) | |
text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section Nested Section | |
section | SI | 1..1 | BackboneElement | IPS Medication Summary Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Medication Summary section |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]} (History of Medication use Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Medications relevant for the scope of the patient summary Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Medication Statement (Trillium II)) | A reference to data that supports this section |
section | SI | 1..1 | BackboneElement | IPS Allergies and Intolerances Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]} (Allergies and adverse reactions Document) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Relevant allergies or intolerances (conditions) for that patient. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Allergy Intolerance (Trillium II)) | A reference to data that supports this section |
section | SI | 1..1 | BackboneElement | IPS Problems Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]} (Problem list - Reported) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Clinical problems or conditions currently being monitored for the patient. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Condition (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS History of Procedures Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"47519-4"}]} (History of Procedures Document) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Patient past procedures pertinent to the scope of this document. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Procedure (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS Immunizations Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"11369-6"}]} (History of Immunization Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Patient's immunization status and pertinent history. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Immunization (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS Medical Devices Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"46264-8"}]} (History of medical device use) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Patient history of medical device use. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Device Use Statement (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS Results Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]} (Relevant diagnostic tests/laboratory data Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..* | Reference(Observation (Results: generic)) | A reference to data that supports this section |
entry | SI | 0..* | Reference(Observation (Results: laboratory)) | A reference to data that supports this section |
entry | SI | 0..* | Reference(Observation (Results: imaging)) | A reference to data that supports this section |
entry | SI | 0..* | Reference(Observation (Results: pathology)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS Vital Signs Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]} (Vital signs) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Notable vital signs or physical findings. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..* | Reference(VitalSigns) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS History of Past Illness Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"11348-0"}]} (History of Past illness Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Conditions the patient suffered in the past. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 1..* | Reference(Condition (Trillium II)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS Functional Status |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"47420-5"}]} (Functional status assessment note) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Optional entry used to represent disabilities and functional assessments Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..* | Reference(Condition (Trillium II)) | A reference to data that supports this section |
entry | SI | 0..* | Reference(ClinicalImpression) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS Plan of Care Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]} (Plan of care note) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS Social History Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"29762-2"}]} (Social history Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..1 | Reference(Observation (SH: tobacco use)) | A reference to data that supports this section |
entry | SI | 0..1 | Reference(Observation (SH: alcohol use)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS History of Pregnancy Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"10162-6"}]} (History of pregnancies Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..* | Reference(Observation (Pregnancy: status)) | A reference to data that supports this section |
entry | SI | 0..* | Reference(Observation (Pregnancy: outcome)) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | IPS Advance Directives Section |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"42348-3"}]} (Advance directives) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | 0..* | Reference(Resource | Consent) | A reference to data that supports this section |
section | SI | 0..1 | BackboneElement | Encounters sections |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: Document Section Codes (example) Fixed Value: {"coding":[{"system":"http://loinc.org","code":"46240-8"}]} (History of Hospitalizations+Outpatient visits Narrative) |
text | SI | 1..1 | Narrative | Text summary of the section, for human interpretation |
mode | ?!Σ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
entry | SI | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open At End by profile:resolve() | |
entry | SI | 0..* | Reference(Encounter (Trillium II)) | A reference to data that supports this section |
Documentation for this format |
Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron