Trillium II Implementation Guide Implementation Guide CI Build

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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

The IPS Composition

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:

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition S0..*International Patient Summary composition
... id S0..1id
... meta S0..1Meta
... text S0..1Narrative
... participant-uv-ips 0..*Reference(PractitionerRole | Organization)Provider to be contacted
URL: http://hl7.eu/fhir/trillium2/StructureDefinition/participant-uv-ips
... identifier S0..1Identifier
... status S1..1code
... type S1..1CodeableConceptKind of composition ("Patient Summary")
.... coding S1..*CodingIPSCode identifying the Patient Summary
..... system S1..1uriFixed Value: http://loinc.org
..... code S1..1codeFixed Value: 60591-5
... subject S1..1Reference(Patient (Trillium II))
.... reference S1..1string
... encounter S0..1Reference(Encounter (Trillium II))
.... reference S1..1string
... date S1..1dateTime
... author S1..*Reference(Practitioner | Device | Patient | RelatedPerson)Who and/or what authored the IPS
.... reference S0..1string
... title S1..1stringInternational Patient Summary
... confidentiality S0..1code
... attester S0..*BackboneElement
.... mode S1..*code
.... time S0..1dateTime
.... party S0..1Reference(Patient | Practitioner | Organization)
..... reference S0..1string
... custodian S0..1Reference(Organization)
.... reference S0..1string
... relatesTo S0..*BackboneElement
.... code S1..1code
.... target[x] S1..1Identifier, Reference(Composition | Trillium II IPS)
... event SBackboneElementSlice: Unordered, Open by value:code
... event S0..1BackboneElementThe care provisioning being documented
.... code S1..*CodeableConceptFixed Value: {"coding":[{"system":"http://terminology.hl7.org/CodeSystem/v3-ActClass","code":"PCPR"}]}
.... period S0..1Period
... section SBackboneElementSections composing the IPS
Slice: Unordered, Open by value:code
... section S1..1BackboneElementIPS Medication Summary Section
.... title S1..1stringMedication Summary section
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"10160-0"}]} (History of Medication use Narrative)
.... text S1..1Narrative
.... entry SReference(Resource)Medications relevant for the scope of the patient summary
Slice: Unordered, Open At End by profile:resolve()
.... entry S1..*Reference(Medication Statement (Trillium II))
.... emptyReason 0..0
.... section 0..0
... section S1..1BackboneElementIPS Allergies and Intolerances Section
.... title S1..1string
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"48765-2"}]} (Allergies and adverse reactions Document)
.... text S1..1Narrative
.... entry SReference(Resource)Relevant allergies or intolerances (conditions) for that patient.
Slice: Unordered, Open At End by profile:resolve()
.... entry S1..*Reference(Allergy Intolerance (Trillium II))
.... emptyReason 0..0
.... section 0..0
... section S1..1BackboneElementIPS Problems Section
.... title S1..1string
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"11450-4"}]} (Problem list - Reported)
.... text S1..1Narrative
.... entry SReference(Resource)Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open At End by profile:resolve()
.... entry S1..*Reference(Condition (Trillium II))
.... emptyReason 0..0
.... section 0..0
... section S0..1BackboneElementIPS History of Procedures Section
.... title S1..1string
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"47519-4"}]} (History of Procedures Document)
.... text S1..1Narrative
.... entry SReference(Resource)Patient past procedures pertinent to the scope of this document.
Slice: Unordered, Open At End by profile:resolve()
.... entry S1..*Reference(Procedure (Trillium II))
.... emptyReason 0..0
.... section 0..0
... section S0..1BackboneElementIPS Immunizations Section
.... title S1..1string
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"11369-6"}]} (History of Immunization Narrative)
.... text S1..1Narrative
.... entry SReference(Resource)Patient's immunization status and pertinent history.
Slice: Unordered, Open At End by profile:resolve()
.... entry S1..*Reference(Immunization (Trillium II))
.... emptyReason 0..0
.... section 0..0
... section S0..1BackboneElementIPS Medical Devices Section
.... title S1..1string
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"46264-8"}]} (History of medical device use)
.... text S1..1Narrative
.... entry SReference(Resource)Patient history of medical device use.
Slice: Unordered, Open At End by profile:resolve()
.... entry S1..*Reference(Device Use Statement (Trillium II))
.... emptyReason 0..0
.... section 0..0
... section S0..1BackboneElementIPS Results Section
.... title S1..1string
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"30954-2"}]} (Relevant diagnostic tests/laboratory data Narrative)
.... text S1..1Narrative
.... entry SReference(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 S0..*Reference(Observation (Results: generic))
.... entry S0..*Reference(Observation (Results: laboratory))
.... entry S0..*Reference(Observation (Results: imaging))
.... entry S0..*Reference(Observation (Results: pathology))
.... emptyReason 0..0
.... section 0..0
... section S0..1BackboneElementIPS Vital Signs Section
.... title S1..1string
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"8716-3"}]} (Vital signs)
.... text S1..1Narrative
.... entry SReference(Resource)Notable vital signs or physical findings.
Slice: Unordered, Open At End by profile:resolve()
.... entry S0..*Reference(VitalSigns)
.... emptyReason 0..0
.... section 0..0
... section S0..1BackboneElementIPS History of Past Illness Section
.... title S1..1string
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"11348-0"}]} (History of Past illness Narrative)
.... text S1..1Narrative
.... entry SReference(Resource)Conditions the patient suffered in the past.
Slice: Unordered, Open At End by profile:resolve()
.... entry S1..*Reference(Condition (Trillium II))
.... emptyReason 0..0
.... section 0..0
... section S0..1BackboneElementIPS Functional Status
.... title S1..1string
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"47420-5"}]} (Functional status assessment note)
.... text S1..1Narrative
.... entry SReference(Resource)Optional entry used to represent disabilities and functional assessments
Slice: Unordered, Open At End by profile:resolve()
.... entry S0..*Reference(Condition (Trillium II))
.... entry S0..*Reference(ClinicalImpression)
.... emptyReason 0..0
.... section 0..0
... section S0..1BackboneElementIPS Plan of Care Section
.... title S1..1string
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"18776-5"}]} (Plan of care note)
.... text S1..1Narrative
.... emptyReason 0..0
.... section 0..0
... section S0..1BackboneElementIPS Social History Section
.... title S1..1string
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"29762-2"}]} (Social history Narrative)
.... text S1..1Narrative
.... entry SReference(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 S0..1Reference(Observation (SH: tobacco use))
.... entry S0..1Reference(Observation (SH: alcohol use))
.... emptyReason 0..0
.... section 0..0
... section S0..1BackboneElementIPS History of Pregnancy Section
.... title S1..1string
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"10162-6"}]} (History of pregnancies Narrative)
.... text S1..1Narrative
.... entry SReference(Resource)Current pregnancy status and, optionally, information about the outcome of earlier pregnancies.
Slice: Unordered, Open At End by profile:resolve()
.... entry S0..*Reference(Observation (Pregnancy: status))
.... entry S0..*Reference(Observation (Pregnancy: outcome))
.... emptyReason 0..0
.... section 0..0
... section S0..1BackboneElementIPS Advance Directives Section
.... title S1..1string
.... code S1..1CodeableConceptIPSFixed Value: {"coding":[{"system":"http://loinc.org","code":"42348-3"}]} (Advance directives)
.... text S1..1Narrative
.... entry S0..*Reference(Resource | Consent)
.... emptyReason 0..0
.... section 0..0
... section S0..1BackboneElementEncounters sections
.... title S1..1string
.... code S1..1CodeableConceptFixed Value: {"coding":[{"system":"http://loinc.org","code":"46240-8"}]} (History of Hospitalizations+Outpatient visits Narrative)
.... text S1..1Narrative
.... entry SReference(Resource)Slice: Unordered, Open At End by profile:resolve()
.... entry S0..*Reference(Encounter (Trillium II))
.... emptyReason 0..0
.... section 0..0

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition SI0..*International Patient Summary composition
... id SΣ0..1idLogical id of this artifact
... meta SΣ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
Max Binding: All Languages
... text SI0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... participant-uv-ips I0..*Reference(PractitionerRole | Organization)Provider to be contacted
URL: http://hl7.eu/fhir/trillium2/StructureDefinition/participant-uv-ips
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..1IdentifierLogical identifier of composition (version-independent)
... status ?!SΣ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣ1..1CodeableConceptKind of composition ("Patient Summary")
Binding: FHIR Document Type Codes (preferred)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... coding SI1..*CodingIPSCode identifying the Patient Summary
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣ1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version SΣ0..1stringVersion of the system - if relevant
..... code SΣ1..1codeSymbol in syntax defined by the system
Fixed Value: 60591-5
..... display SΣ0..1stringRepresentation defined by the system
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
...... translation SI0..*(Complex)Language Translation (Localization)
URL: http://hl7.org/fhir/StructureDefinition/translation
...... value 0..1Primitive value for string
Max Length: 1048576
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... class Σ0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... subject SΣ1..1Reference(Patient (Trillium II))Who and/or what the composition is about
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... encounter SΣ0..1Reference(Encounter (Trillium II))Context of the Composition
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... date SΣ1..1dateTimeComposition editing time
... author SΣ1..*Reference(Practitioner | Device | Patient | RelatedPerson)Who and/or what authored the IPS
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI0..1stringLiteral reference, Relative, internal or absolute URL
.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... title SΣ1..1stringInternational Patient Summary
... confidentiality ?!SΣ0..1codeAs defined by affinity domain
Binding: ConfidentialityClassification (required)
... attester SΣI0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... mode SΣ1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time SΣ0..1dateTimeWhen the composition was attested
.... party SΣ0..1Reference(Patient | Practitioner | Organization)Who attested the composition
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣI0..1stringLiteral reference, Relative, internal or absolute URL
..... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
..... display Σ0..1stringText alternative for the resource
... custodian SΣ0..1Reference(Organization)Organization which maintains the composition
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI0..1stringLiteral reference, Relative, internal or absolute URL
.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... relatesTo SΣI0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code SΣ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] SΣ1..1Identifier, Reference(Composition | Trillium II IPS)Target of the relationship
... event SΣIBackboneElementThe clinical service(s) being documented
Slice: Unordered, Open by value:code
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: ActCode (example)
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... event SΣI0..1BackboneElementThe care provisioning being documented
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code SΣ1..*CodeableConceptCode(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 SΣ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section SIBackboneElementSections composing the IPS
Slice: Unordered, Open by value:code
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: Document Section Codes (example)
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section
Nested Section
... section SI1..1BackboneElementIPS Medication Summary Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringMedication Summary section
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SIReference(Resource)Medications relevant for the scope of the patient summary
Slice: Unordered, Open At End by profile:resolve()
.... entry SI1..*Reference(Medication Statement (Trillium II))A reference to data that supports this section
... section SI1..1BackboneElementIPS Allergies and Intolerances Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SIReference(Resource)Relevant allergies or intolerances (conditions) for that patient.
Slice: Unordered, Open At End by profile:resolve()
.... entry SI1..*Reference(Allergy Intolerance (Trillium II))A reference to data that supports this section
... section SI1..1BackboneElementIPS Problems Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SIReference(Resource)Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open At End by profile:resolve()
.... entry SI1..*Reference(Condition (Trillium II))A reference to data that supports this section
... section SI0..1BackboneElementIPS History of Procedures Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SIReference(Resource)Patient past procedures pertinent to the scope of this document.
Slice: Unordered, Open At End by profile:resolve()
.... entry SI1..*Reference(Procedure (Trillium II))A reference to data that supports this section
... section SI0..1BackboneElementIPS Immunizations Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SIReference(Resource)Patient's immunization status and pertinent history.
Slice: Unordered, Open At End by profile:resolve()
.... entry SI1..*Reference(Immunization (Trillium II))A reference to data that supports this section
... section SI0..1BackboneElementIPS Medical Devices Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SIReference(Resource)Patient history of medical device use.
Slice: Unordered, Open At End by profile:resolve()
.... entry SI1..*Reference(Device Use Statement (Trillium II))A reference to data that supports this section
... section SI0..1BackboneElementIPS Results Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SIReference(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 SI0..*Reference(Observation (Results: generic))A reference to data that supports this section
.... entry SI0..*Reference(Observation (Results: laboratory))A reference to data that supports this section
.... entry SI0..*Reference(Observation (Results: imaging))A reference to data that supports this section
.... entry SI0..*Reference(Observation (Results: pathology))A reference to data that supports this section
... section SI0..1BackboneElementIPS Vital Signs Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SIReference(Resource)Notable vital signs or physical findings.
Slice: Unordered, Open At End by profile:resolve()
.... entry SI0..*Reference(VitalSigns)A reference to data that supports this section
... section SI0..1BackboneElementIPS History of Past Illness Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SIReference(Resource)Conditions the patient suffered in the past.
Slice: Unordered, Open At End by profile:resolve()
.... entry SI1..*Reference(Condition (Trillium II))A reference to data that supports this section
... section SI0..1BackboneElementIPS Functional Status
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SIReference(Resource)Optional entry used to represent disabilities and functional assessments
Slice: Unordered, Open At End by profile:resolve()
.... entry SI0..*Reference(Condition (Trillium II))A reference to data that supports this section
.... entry SI0..*Reference(ClinicalImpression)A reference to data that supports this section
... section SI0..1BackboneElementIPS Plan of Care Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
... section SI0..1BackboneElementIPS Social History Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SIReference(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 SI0..1Reference(Observation (SH: tobacco use))A reference to data that supports this section
.... entry SI0..1Reference(Observation (SH: alcohol use))A reference to data that supports this section
... section SI0..1BackboneElementIPS History of Pregnancy Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SIReference(Resource)Current pregnancy status and, optionally, information about the outcome of earlier pregnancies.
Slice: Unordered, Open At End by profile:resolve()
.... entry SI0..*Reference(Observation (Pregnancy: status))A reference to data that supports this section
.... entry SI0..*Reference(Observation (Pregnancy: outcome))A reference to data that supports this section
... section SI0..1BackboneElementIPS Advance Directives Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code SI1..1CodeableConceptIPSConcept - 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SI0..*Reference(Resource | Consent)A reference to data that supports this section
... section SI0..1BackboneElementEncounters sections
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title S1..1stringLabel for section (e.g. for ToC)
.... code S1..1CodeableConceptClassification 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 SI1..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry SIReference(Resource)A reference to data that supports this section
Slice: Unordered, Open At End by profile:resolve()
.... entry SI0..*Reference(Encounter (Trillium II))A reference to data that supports this section

doco Documentation for this format

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