This page is part of the HL7 Europe Laboratory Report (v0.1.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
Page standards status: Trial-use | Maturity Level: 2 |
Definitions for the Composition-eu-lab resource profile.
Guidance on how to interpret the contents of this table can be found here
0. Composition | |
Definition | Laboratory Report composition. A 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. While 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. |
Short | Laboratory Report composition |
2. Composition.text | |
Short | Narrative text |
4. Composition.extension:basedOn-order-or-requisition | |
Slice Name | basedOn-order-or-requisition |
Control | 0..* |
Type | Extension(Document Based On Order) (Extension Type: Choice of: Identifier, Reference(ServiceRequest)) |
6. Composition.extension:basedOn-order-or-requisition.value[x] | |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Slicing | This element introduces a set of slices on Composition.extension.value[x] . The slices are unordered and Open, and can be differentiated using the following discriminators: |
8. Composition.extension:basedOn-order-or-requisition.value[x]:valueReference | |
Slice Name | valueReference |
Control | 0..1 |
Type | Reference(ServiceRequest: Laboratory Order) |
[x] Note | See Choice of Data Types for further information about how to use [x] |
10. Composition.extension:information-recipient | |
Slice Name | information-recipient |
Control | 0..* |
Type | Extension(Information recipient) (Extension Type: Reference(Practitioner, Device, Patient, RelatedPerson, PractitionerRole, Organization)) |
12. Composition.extension:information-recipient.value[x] | |
Type | Reference(Practitioner: Laboratory Report, Device, Patient: Person, RelatedPerson, PractitionerRole: Laboratory Report, Organization) |
[x] Note | See Choice of Data Types for further information about how to use [x] |
14. Composition.extension:diagnosticReport-reference | |
Slice Name | diagnosticReport-reference |
Control | 0..1 |
Type | Extension(Document DiagnosticReport Reference) (Extension Type: Reference(DiagnosticReport)) |
16. Composition.extension:diagnosticReport-reference.value[x] | |
Control | 1..? |
Type | Reference(DiagnosticReport: Laboratory Report) |
[x] Note | See Choice of Data Types for further information about how to use [x] |
18. Composition.extension:diagnosticReport-reference.value[x].reference | |
Comments | Added to the FHIR R4 guide to strctly conform with the R4 rules for document bundle resources inclusion. Using this extension implies to accept a circular reference Composition to/from DiagnosticReport |
Control | 1..? |
20. Composition.identifier | |
Definition | Identifiers assigned to this Laboratory Report by the performer or other systems. It shall be common to several report versions |
Short | Report identifier |
Comments | Composition.identifier SHALL be equal to one of the DiagnosticReport.identifier, if at least one exists |
Note | This is a business identifier, not a resource identifier (see discussion) |
22. Composition.status | |
Short | Status of the Report |
Comments | DiagnosticReport.status and Composition.status shall be aligned, based on the http://hl7.eu/fhir/laboratory/ConceptMap/ConceptMap-eu-diagRptStatus2CompStatus mapping |
24. Composition.type | |
Definition | Specifies that it refers to a Laboratory Report |
Short | Type of (Laboratory) Report |
Comments | At least one DiagnosticReport.code.coding and Composition.type.coding SHALL be equal |
Binding | The codes SHOULD be taken from Laboratory Report Types (preferred to http://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab ) |
Type | CodeableConcept(Codeable Concept (IPS)) |
26. Composition.category | |
Definition | A code that classifies this laboratory report. Two basic categories has been selected in this guide: laboratory specialty and Study type. Laboratory specialty is characteristic of the laboratory that produced the test result while Study type is an arbitrary classificion of the test type. |
Short | Report Category |
Comments | DiagnosticReport.category and Composition.category shall be aligned |
Type | CodeableConcept(Codeable Concept (IPS)) |
Slicing | This element introduces a set of slices on Composition.category . The slices are unordered and Open, and can be differentiated using the following discriminators: |
28. Composition.category:studyType | |
Slice Name | studyType |
Definition | Laboratory services, i.e., results of tests performed, could be characterized using typology of services, commonly called study types. Study type could be seen as an attribute or grouping mechanism that assigns a common clinical sense to certain types of laboratory test results., e.g., Hemoglobin, Platelet count, etc. belongs to 'Hematology study'. |
Short | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) |
Comments | In comparison to the laboratory specialty which is an attribute of laboratory, study type is a categorization of laboratory service. It needs to be mentioned that classification of test to study types in not standardized. |
Control | 0..* |
Binding | The codes SHALL be taken from Laboratory Study Types (required to http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab ) |
30. Composition.category:specialty | |
Slice Name | specialty |
Definition | Laboratory specialty is an attribute of any laboratory setting representing professional qualification of the laboratory to execute certain kind of laboratory tests. |
Short | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) |
Comments | Specialty could be used as parameter for searching/querying of laboratory test results. |
Control | 0..* |
Binding | The codes SHALL be taken from Laboratory Specialty (required to http://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab ) |
32. Composition.subject | |
Definition | Who or what this report is about. The report can be about a human patient, a living subject, a device (e.g. a machine), a location 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). |
Short | Who and/or what this report is about |
Comments | DiagnosticReport and Composition SHALL have the same subject |
Control | 1..? |
Type | Reference(Patient: Person, Patient: Animal, Group, Location, Device) |
34. Composition.encounter | |
Definition | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. |
Short | The healthcare event which this Laboratory Report is about (when test ordered). |
Comments | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). DiagnosticReport and Composition SHALL have the same encounter. |
36. Composition.author | |
Definition | Identifies who is responsible for the information in the Laboratory Report, not necessarily who typed it in. |
Short | Who and/or what authored the Laboratory Report |
Comments | If a DiagnosticReport.resultsInterpreter exists this is expected to be a Composition.author; otherwise a DiagnosticReport.performer should be an author. |
38. Composition.title | |
Definition | Official human-readable label for the composition. For this document should be "Laboratory Report" or any equivalent translation |
Short | Laboratory Report |
40. Composition.attester | |
Short | Attests the report accuracy |
42. Composition.attester.mode | |
Short | The type of attestation |
44. Composition.attester.time | |
Short | When the report was attested by the party |
46. Composition.attester.party | |
Short | Who attested the report |
Comments | For a Laboratory Report it is usually non expected that the attester would be a Patient or a RealtedPerson |
48. Composition.event | |
Short | The laboratory service(s) being documented |
50. Composition.event.code | |
Short | Code(s) that apply to the laboratory service(s) being documented |
52. Composition.event.period | |
Short | Period of time covered by the documentation |
54. Composition.event.detail | |
Short | The laboratory service(s) being documented |
56. Composition.section | |
Definition | The "body" of the report is organized as a tree of up to two levels of sections: top level sections represent laboratory specialties. A top level section SHALL contain either one text block carrying all the text results produced for this specialty along with Laboratory Data Entries or a set of Laboratory Report Item Sections. In the first case the specialty section happens to also be a leaf section. In the latter case, each (second level) leaf section contained in the (top level) specialty section represents a Report Item: i.e., a battery, a specimen study (especially in microbiology), or an individual test. In addition, any leaf section SHALL contain a Laboratory Data Entries containing the observations of that section in a machine-readable format. |
Control | 1..? |
Slicing | This element introduces a set of slices on Composition.section . The slices are unordered and Open, and can be differentiated using the following discriminators: |
58. Composition.section.title | |
Control | 1..? |
60. Composition.section.code | |
Control | 1..? |
Type | CodeableConcept(Codeable Concept (IPS)) |
62. Composition.section:lab-no-subsections | |
Slice Name | lab-no-subsections |
Definition | Variant 1: With this option, all laboratory report data entries are provided in the top level sections and no sub-sections are allowed. |
Short | Variant 1: EU Laboratory Report section with entries and no sub-sections |
Control | 0..* |
64. Composition.section:lab-no-subsections.code | |
Binding | The codes SHOULD be taken from Laboratory Study Types (preferred to http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab ) |
66. Composition.section:lab-no-subsections.text | |
Short | Text summary of the section, for human interpretation. |
68. Composition.section:lab-no-subsections.entry | |
Control | 1..? |
Type | Reference(Observation Results: laboratory) |
70. Composition.section:lab-no-subsections.section | |
Control | 0..0 |
72. Composition.section:lab-subsections | |
Slice Name | lab-subsections |
Definition | Variant 2: With this option, this top level section doesn't include NEITHER a top level text NOR entry elements. Each Report Item is contained in a corresponding sub-sections which contains the Lab Report Data Entry. |
Short | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item |
Control | 0..* |
74. Composition.section:lab-subsections.code | |
Binding | The codes SHOULD be taken from Laboratory Study Types (preferred to http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab ) |
76. Composition.section:lab-subsections.text | |
Control | 0..0 |
78. Composition.section:lab-subsections.entry | |
Control | 0..0 |
80. Composition.section:lab-subsections.section | |
Control | 1..? |
Type | BackboneElement |
82. Composition.section:lab-subsections.section.title | |
Control | 1..? |
84. Composition.section:lab-subsections.section.code | |
Control | 1..? |
Binding | The codes SHOULD be taken from Laboratory Study Types (preferred to http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab ) |
Type | CodeableConcept(Codeable Concept (IPS)) |
86. Composition.section:lab-subsections.section.text | |
Short | Text summary of the section, for human interpretation. |
88. Composition.section:lab-subsections.section.entry | |
Control | 1..? |
Type | Reference(Observation Results: laboratory) |
90. Composition.section:lab-subsections.section.section | |
Control | 0..0 |
92. Composition.section:annotations | |
Slice Name | annotations |
Definition | Narrative expression of comments accompanying the report, such as suggestions for evaluation, technical notes from the laboratory, etc. Examples: Suggestion: This result should be evaluated in relation to the patient's medical history and clinical condition. Technical note: A list of accredited examination(s) is available at www.laboratory.com. |
Short | Annotation comment |
Control | 0..* |
94. Composition.section:annotations.code | |
Pattern Value | { |
96. Composition.section:annotations.text | |
Control | 1..? |
98. Composition.section:annotations.entry | |
Control | 0..0 |
100. Composition.section:annotations.section | |
Control | 0..0 |
Guidance on how to interpret the contents of this table can be found here
0. Composition | |
Definition | Laboratory Report composition. A 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. While 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. A set of healthcare-related information that is assembled together into a single logical package 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. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). |
Short | Laboratory Report compositionA set of resources composed into a single coherent clinical statement with clinical attestation |
Comments | 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. |
Control | 0..* |
Is Modifier | false |
Summary | false |
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: 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 (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()) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) |
2. Composition.implicitRules | |
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. |
Short | A set of rules under which this content was created |
Comments | 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. |
Control | 0..1 |
Type | uri |
Is Modifier | true because 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 |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
4. Composition.text | |
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. |
Short | Narrative textText summary of the resource, for human interpretation |
Comments | 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. |
Control | 0..1 |
Type | Narrative |
Is Modifier | false |
Summary | false |
Alternate Names | narrative, html, xhtml, display |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
6. Composition.extension:versionNumber | |
Slice Name | versionNumber |
Definition | Version specific identifier for the composition, assigned when each version is created/updated. |
Short | Version-specific identifier for composition |
Comments | While each resource, including the composition itself, has its own version identifier, this is a formal identifier for the logical version of the composition as a whole. It would remain constant if the resources were moved to a new server, and all got new individual resource versions, for example. |
Control | 0..* This element is affected by the following invariants: ele-1 |
Type | Extension(versionNumber) (Extension Type: string) |
Is Modifier | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() )ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
8. Composition.extension:basedOn-order-or-requisition | |
Slice Name | basedOn-order-or-requisition |
Definition | This extension provides a link to the order [(Reference(ServiceRequest)] or requisition [ServiceRequest.requisition (i.e., 'Request.groupIdentifier')] that this report document is based on and fulfills. |
Short | Document Based On Order |
Control | 0..* |
Type | Extension(Document Based On Order) (Extension Type: Choice of: Identifier, Reference(ServiceRequest)) |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
10. Composition.extension:basedOn-order-or-requisition.extension | |
Definition | An Extension 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. |
Short | ExtensionAdditional content defined by implementations |
Comments | 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. |
Control | 0..0* |
Type | Extension |
Is Modifier | false |
Summary | false |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
Slicing | This element introduces a set of slices on Composition.extension.extension . The slices are unordered and Open, and can be differentiated using the following discriminators: |
12. Composition.extension:basedOn-order-or-requisition.url | |
Definition | Source of the definition for the extension code - a logical name or a URL. |
Short | identifies the meaning of the extension |
Comments | 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. |
Control | 1..1 |
Type | uri |
Is Modifier | false |
XML Format | In the XML format, this property is represented as an attribute. |
Summary | false |
Fixed Value | http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition |
14. Composition.extension:basedOn-order-or-requisition.value[x] | |
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). |
Short | Value of extension |
Control | 0..1 |
Type | Reference(ServiceRequest), date, Meta, Address, Attachment, integer, Count, DataRequirement, Dosage, uuid, Identifier, Coding, SampledData, id, positiveInt, Distance, Period, Duration, canonical, Range, RelatedArtifact, base64Binary, UsageContext, Timing, decimal, CodeableConcept, ParameterDefinition, dateTime, code, string, Contributor, oid, instant, ContactPoint, HumanName, Money, markdown, Ratio, Age, TriggerDefinition, Quantity, uri, url, Annotation, ContactDetail, boolean, Expression, Signature, unsignedInt, time |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on Composition.extension.value[x] . The slices are unordered and Closed, and can be differentiated using the following discriminators: |
16. Composition.extension:basedOn-order-or-requisition.value[x]:valueReference | |
Slice Name | valueReference |
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). |
Short | Value of extension |
Control | 0..1 |
Type | Reference(ServiceRequest: Laboratory Order), date, Meta, Address, Attachment, integer, Count, DataRequirement, Dosage, uuid, Identifier, Coding, SampledData, id, positiveInt, Distance, Period, Duration, canonical, Range, RelatedArtifact, base64Binary, UsageContext, Timing, decimal, CodeableConcept, ParameterDefinition, dateTime, code, string, Contributor, oid, instant, ContactPoint, HumanName, Money, markdown, Ratio, Age, TriggerDefinition, Quantity, uri, url, Annotation, ContactDetail, boolean, Expression, Signature, unsignedInt, time |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
18. Composition.extension:information-recipient | |
Slice Name | information-recipient |
Definition | This extension applies to the Composition resource and is used to represent an intended recipient of the composition. |
Short | Information recipient |
Control | 0..* |
Type | Extension(Information recipient) (Extension Type: Reference(Practitioner, Device, Patient, RelatedPerson, PractitionerRole, Organization)) |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
20. Composition.extension:information-recipient.extension | |
Definition | An Extension 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. |
Short | ExtensionAdditional content defined by implementations |
Comments | 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. |
Control | 0..0* |
Type | Extension |
Is Modifier | false |
Summary | false |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
Slicing | This element introduces a set of slices on Composition.extension.extension . The slices are unordered and Open, and can be differentiated using the following discriminators: |
22. Composition.extension:information-recipient.url | |
Definition | Source of the definition for the extension code - a logical name or a URL. |
Short | identifies the meaning of the extension |
Comments | 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. |
Control | 1..1 |
Type | uri |
Is Modifier | false |
XML Format | In the XML format, this property is represented as an attribute. |
Summary | false |
Fixed Value | http://hl7.eu/fhir/StructureDefinition/information-recipient |
24. Composition.extension:information-recipient.value[x] | |
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). |
Short | Value of extension |
Control | 0..1 |
Type | Reference(Practitioner: Laboratory Report, Device, Patient: Person, RelatedPerson, PractitionerRole: Laboratory Report, Organization), date, Meta, Address, Attachment, integer, Count, DataRequirement, Dosage, uuid, Identifier, Coding, SampledData, id, positiveInt, Distance, Period, Duration, canonical, Range, RelatedArtifact, base64Binary, UsageContext, Timing, decimal, CodeableConcept, ParameterDefinition, dateTime, code, string, Contributor, oid, instant, ContactPoint, HumanName, Money, markdown, Ratio, Age, TriggerDefinition, Quantity, uri, url, Annotation, ContactDetail, boolean, Expression, Signature, unsignedInt, time |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
26. Composition.extension:diagnosticReport-reference | |
Slice Name | diagnosticReport-reference |
Definition | This extension provides a reference to the DiagnosticReport instance that is associated with this Composition. |
Short | Document DiagnosticReport Reference |
Control | 0..1 |
Type | Extension(Document DiagnosticReport Reference) (Extension Type: Reference(DiagnosticReport)) |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
28. Composition.extension:diagnosticReport-reference.extension | |
Definition | An Extension 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. |
Short | ExtensionAdditional content defined by implementations |
Comments | 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. |
Control | 0..0* |
Type | Extension |
Is Modifier | false |
Summary | false |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
Slicing | This element introduces a set of slices on Composition.extension.extension . The slices are unordered and Open, and can be differentiated using the following discriminators: |
30. Composition.extension:diagnosticReport-reference.url | |
Definition | Source of the definition for the extension code - a logical name or a URL. |
Short | identifies the meaning of the extension |
Comments | 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. |
Control | 1..1 |
Type | uri |
Is Modifier | false |
XML Format | In the XML format, this property is represented as an attribute. |
Summary | false |
Fixed Value | http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference |
32. Composition.extension:diagnosticReport-reference.value[x] | |
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). |
Short | Value of extension |
Control | 10..1 |
Type | Reference(DiagnosticReport: Laboratory Report), date, Meta, Address, Attachment, integer, Count, DataRequirement, Dosage, uuid, Identifier, Coding, SampledData, id, positiveInt, Distance, Period, Duration, canonical, Range, RelatedArtifact, base64Binary, UsageContext, Timing, decimal, CodeableConcept, ParameterDefinition, dateTime, code, string, Contributor, oid, instant, ContactPoint, HumanName, Money, markdown, Ratio, Age, TriggerDefinition, Quantity, uri, url, Annotation, ContactDetail, boolean, Expression, Signature, unsignedInt, time |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
34. Composition.extension:diagnosticReport-reference.value[x].reference | |
Definition | A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. |
Short | Literal reference, Relative, internal or absolute URL |
Comments | Added to the FHIR R4 guide to strctly conform with the R4 rules for document bundle resources inclusion. Using this extension implies to accept a circular reference Composition to/from DiagnosticReport Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. |
Control | 10..1 This element is affected by the following invariants: ref-1 |
Type | string |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
36. Composition.modifierExtension | |
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored |
Comments | 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them |
Summary | false |
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. 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. |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
38. Composition.identifier | |
Definition | Identifiers assigned to this Laboratory Report by the performer or other systems. It shall be common to several report versions A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time. |
Short | Report identifierVersion-independent identifier for the Composition |
Comments | Composition.identifier SHALL be equal to one of the DiagnosticReport.identifier, if at least one exists Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate. |
Note | This is a business identifier, not a resource identifier (see discussion) |
Control | 0..1 |
Type | Identifier |
Is Modifier | false |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
40. Composition.status | |
Definition | The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. |
Short | Status of the Reportpreliminary | final | amended | entered-in-error |
Comments | DiagnosticReport.status and Composition.status shall be aligned, based on the http://hl7.eu/fhir/laboratory/ConceptMap/ConceptMap-eu-diagRptStatus2CompStatus mapping 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. Some 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. |
Control | 1..1 |
Binding | The codes SHALL be taken from CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 (required to http://hl7.org/fhir/ValueSet/composition-status|4.0.1 )The workflow/clinical status of the composition. |
Type | code |
Is Modifier | true because 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 |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Requirements | Need to be able to mark interim, amended, or withdrawn compositions or documents. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
42. Composition.type | |
Definition | Specifies that it refers to a Laboratory Report Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. |
Short | Type of (Laboratory) ReportKind of composition (LOINC if possible) |
Comments | At least one DiagnosticReport.code.coding and Composition.type.coding SHALL be equal 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. |
Control | 1..1 This element is affected by the following invariants: ele-1 |
Binding | The codes SHOULD be taken from Laboratory Report Typeshttp://hl7.org/fhir/ValueSet/doc-typecodes (preferred to http://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab ) |
Type | CodeableConcept(Codeable Concept (IPS)) |
Is Modifier | false |
Requirements | Key metadata element describing the composition, used in searching/filtering. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
44. Composition.category | |
Definition | A code that classifies this laboratory report. Two basic categories has been selected in this guide: laboratory specialty and Study type. Laboratory specialty is characteristic of the laboratory that produced the test result while Study type is an arbitrary classificion of the test type. 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. |
Short | Report CategoryCategorization of Composition |
Comments | DiagnosticReport.category and Composition.category shall be aligned This is a metadata field from XDS/MHD. |
Control | 0..* |
Binding | For example codes, see DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes (example to http://hl7.org/fhir/ValueSet/document-classcodes )High-level kind of a clinical document at a macro level. |
Type | CodeableConcept(Codeable Concept (IPS)) |
Is Modifier | false |
Summary | true |
Requirements | Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on Composition.category . The slices are unordered and Open, and can be differentiated using the following discriminators: |
46. Composition.category:studyType | |
Slice Name | studyType |
Definition | Laboratory services, i.e., results of tests performed, could be characterized using typology of services, commonly called study types. Study type could be seen as an attribute or grouping mechanism that assigns a common clinical sense to certain types of laboratory test results., e.g., Hemoglobin, Platelet count, etc. belongs to 'Hematology study'. 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. |
Short | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.)Categorization of Composition |
Comments | In comparison to the laboratory specialty which is an attribute of laboratory, study type is a categorization of laboratory service. It needs to be mentioned that classification of test to study types in not standardized. This is a metadata field from XDS/MHD. |
Control | 0..* |
Binding | The codes SHALL be taken from For example codes, see Laboratory Study Typeshttp://hl7.org/fhir/ValueSet/document-classcodes (required to http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
48. Composition.category:specialty | |
Slice Name | specialty |
Definition | Laboratory specialty is an attribute of any laboratory setting representing professional qualification of the laboratory to execute certain kind of laboratory tests. 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. |
Short | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry)Categorization of Composition |
Comments | Specialty could be used as parameter for searching/querying of laboratory test results. This is a metadata field from XDS/MHD. |
Control | 0..* |
Binding | The codes SHALL be taken from For example codes, see Laboratory Specialtyhttp://hl7.org/fhir/ValueSet/document-classcodes (required to http://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Requirements | Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
50. Composition.subject | |
Definition | Who or what this report is about. The report can be about a human patient, a living subject, a device (e.g. a machine), a location 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). Who or what the composition is about. The 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). |
Short | Who and/or what this report is aboutWho and/or what the composition is about |
Comments | DiagnosticReport and Composition SHALL have the same subject For clinical documents, this is usually the patient. |
Control | 10..1 |
Type | Reference(Patient: Person, Patient: Animal, Group, Location, Device, Resource) |
Is Modifier | false |
Summary | true |
Requirements | Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
52. Composition.encounter | |
Definition | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. Describes the clinical encounter or type of care this documentation is associated with. |
Short | The healthcare event which this Laboratory Report is about (when test ordered).Context of the Composition |
Comments | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). DiagnosticReport and Composition SHALL have the same encounter. |
Control | 0..1 |
Type | Reference(Encounter) |
Is Modifier | false |
Summary | true |
Requirements | Provides context for the composition and supports searching. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
54. Composition.date | |
Definition | The composition editing time, when the composition was last logically changed by the author. |
Short | Composition editing time |
Comments | The Last Modified Date on the composition may be after the date of the document was attested without being changed. |
Control | 1..1 |
Type | dateTime |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
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 is the date of packaging. dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
56. Composition.author | |
Definition | Identifies who is responsible for the information in the Laboratory Report, not necessarily who typed it in. Identifies who is responsible for the information in the composition, not necessarily who typed it in. |
Short | Who and/or what authored the Laboratory ReportWho and/or what authored the composition |
Comments | If a DiagnosticReport.resultsInterpreter exists this is expected to be a Composition.author; otherwise a DiagnosticReport.performer should be an author. |
Control | 1..* |
Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) |
Is Modifier | false |
Summary | true |
Requirements | Identifies who is responsible for the content. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
58. Composition.title | |
Definition | Official human-readable label for the composition. For this document should be "Laboratory Report" or any equivalent translation Official human-readable label for the composition. |
Short | Laboratory ReportHuman Readable name/title |
Comments | 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. |
Control | 1..1 |
Type | string |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
60. Composition.attester | |
Definition | A participant who has attested to the accuracy of the composition/document. |
Short | Attests the report accuracyAttests to accuracy of composition |
Comments | Only list each attester once. |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Summary | false |
Requirements | Identifies responsibility for the accuracy of the composition content. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
62. Composition.attester.modifierExtension | |
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
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. 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. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
64. Composition.attester.mode | |
Definition | The type of attestation the authenticator offers. |
Short | The type of attestationpersonal | professional | legal | official |
Control | 1..1 |
Binding | The codes SHALL be taken from CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 (required to http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 )The way in which a person authenticated a composition. |
Type | code |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Indicates the level of authority of the attestation. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
66. Composition.attester.time | |
Definition | When the composition was attested by the party. |
Short | When the report was attested by the partyWhen the composition was attested |
Control | 0..1 |
Type | dateTime |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Identifies when the information in the composition was deemed accurate. (Things may have changed since then.). |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
68. Composition.attester.party | |
Definition | Who attested the composition in the specified way. |
Short | Who attested the reportWho attested the composition |
Comments | For a Laboratory Report it is usually non expected that the attester would be a Patient or a RealtedPerson |
Control | 0..1 |
Type | Reference(Patient, RelatedPerson, Practitioner, PractitionerRole, Organization) |
Is Modifier | false |
Summary | false |
Requirements | Identifies who has taken on the responsibility for accuracy of the composition content. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
70. Composition.event | |
Definition | The clinical service, such as a colonoscopy or an appendectomy, being documented. |
Short | The laboratory service(s) being documentedThe clinical service(s) being documented |
Comments | The event needs to be consistent with the type element, though can provide further information if desired. |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Summary | true |
Requirements | Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
72. Composition.event.modifierExtension | |
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
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. 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. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
74. Composition.event.code | |
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. |
Short | Code(s) that apply to the laboratory service(s) being documentedCode(s) that apply to the event being documented |
Comments | 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. |
Control | 0..* |
Binding | For example codes, see v3 Code System ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode (example to http://terminology.hl7.org/ValueSet/v3-ActCode )This list of codes represents the main clinical acts being documented. |
Type | CodeableConcept |
Is Modifier | false |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
76. Composition.event.period | |
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. |
Short | Period of time covered by the documentationThe period covered by the documentation |
Control | 0..1 |
Type | Period |
Is Modifier | false |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
78. Composition.event.detail | |
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. |
Short | The laboratory service(s) being documentedThe event(s) being documented |
Control | 0..* |
Type | Reference(Resource) |
Is Modifier | false |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
80. Composition.section | |
Definition | The "body" of the report is organized as a tree of up to two levels of sections: top level sections represent laboratory specialties. A top level section SHALL contain either one text block carrying all the text results produced for this specialty along with Laboratory Data Entries or a set of Laboratory Report Item Sections. In the first case the specialty section happens to also be a leaf section. In the latter case, each (second level) leaf section contained in the (top level) specialty section represents a Report Item: i.e., a battery, a specimen study (especially in microbiology), or an individual test. In addition, any leaf section SHALL contain a Laboratory Data Entries containing the observations of that section in a machine-readable format. The root of the sections that make up the composition. |
Short | Composition is broken into sections |
Control | 10..* |
Type | BackboneElement |
Is Modifier | false |
Summary | false |
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists() )cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty() )ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
Slicing | This element introduces a set of slices on Composition.section . The slices are unordered and Open, and can be differentiated using the following discriminators: |
82. Composition.section.modifierExtension | |
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
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. 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. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
84. Composition.section.title | |
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. |
Short | Label for section (e.g. for ToC) |
Comments | 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. |
Control | 10..1 |
Type | string |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. |
Alternate Names | header, label, caption |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
86. Composition.section.code | |
Definition | A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. A code identifying the kind of content contained within the section. This must be consistent with the section title. |
Short | Concept - reference to a terminology or just textClassification of section (recommended) |
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. 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. If 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. |
Control | 10..1 This element is affected by the following invariants: ele-1 |
Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes (example to http://hl7.org/fhir/ValueSet/doc-section-codes )Classification of a section of a composition/document. |
Type | CodeableConcept(Codeable Concept (IPS)) |
Is Modifier | false |
Requirements | Provides computable standardized labels to topics within the document. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
88. Composition.section:lab-no-subsections | |
Slice Name | lab-no-subsections |
Definition | Variant 1: With this option, all laboratory report data entries are provided in the top level sections and no sub-sections are allowed. The root of the sections that make up the composition. |
Short | Variant 1: EU Laboratory Report section with entries and no sub-sectionsComposition is broken into sections |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Summary | false |
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists() )cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty() )ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
90. Composition.section:lab-no-subsections.modifierExtension | |
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
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. 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. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
92. Composition.section:lab-no-subsections.code | |
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title. |
Short | Classification of section (recommended) |
Comments | 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. If 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. |
Control | 0..1 |
Binding | The codes SHOULD be taken from For example codes, see Laboratory Study Typeshttp://hl7.org/fhir/ValueSet/doc-section-codes (preferred to http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Provides computable standardized labels to topics within the document. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
94. Composition.section:lab-no-subsections.text | |
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. |
Short | Text summary of the section, for human interpretation. |
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
Control | 0..1 This element is affected by the following invariants: cmp-1 |
Type | Narrative |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
96. Composition.section:lab-no-subsections.entry | |
Definition | A reference to the actual resource from which the narrative in the section is derived. |
Short | A reference to data that supports this section |
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
Control | 10..* This element is affected by the following invariants: cmp-2 |
Type | Reference(Observation Results: laboratory, Resource) |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
98. Composition.section:lab-no-subsections.section | |
Definition | A nested sub-section within this section. |
Short | Nested Section |
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. |
Control | 0..0* This element is affected by the following invariants: cmp-1 |
Type | See ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
100. Composition.section:lab-subsections | |
Slice Name | lab-subsections |
Definition | Variant 2: With this option, this top level section doesn't include NEITHER a top level text NOR entry elements. Each Report Item is contained in a corresponding sub-sections which contains the Lab Report Data Entry. The root of the sections that make up the composition. |
Short | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report ItemComposition is broken into sections |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Summary | false |
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists() )cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty() )ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
102. Composition.section:lab-subsections.modifierExtension | |
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
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. 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. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
104. Composition.section:lab-subsections.code | |
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title. |
Short | Classification of section (recommended) |
Comments | 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. If 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. |
Control | 0..1 |
Binding | The codes SHOULD be taken from For example codes, see Laboratory Study Typeshttp://hl7.org/fhir/ValueSet/doc-section-codes (preferred to http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab ) |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Provides computable standardized labels to topics within the document. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
106. Composition.section:lab-subsections.text | |
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. |
Short | Text summary of the section, for human interpretation |
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
Control | 0..01 This element is affected by the following invariants: cmp-1 |
Type | Narrative |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
108. Composition.section:lab-subsections.entry | |
Definition | A reference to the actual resource from which the narrative in the section is derived. |
Short | A reference to data that supports this section |
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
Control | 0..0* This element is affected by the following invariants: cmp-2 |
Type | Reference(Resource) |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
110. Composition.section:lab-subsections.section | |
Definition | A nested sub-section within this section. |
Short | Nested Section |
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. |
Control | 10..* This element is affected by the following invariants: cmp-1 |
Type | BackboneElement |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
112. Composition.section:lab-subsections.section.modifierExtension | |
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
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. 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. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
114. Composition.section:lab-subsections.section.title | |
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. |
Short | Label for section (e.g. for ToC) |
Comments | 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. |
Control | 10..1 |
Type | string |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | false |
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. |
Alternate Names | header, label, caption |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
116. Composition.section:lab-subsections.section.code | |
Definition | A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. A code identifying the kind of content contained within the section. This must be consistent with the section title. |
Short | Concept - reference to a terminology or just textClassification of section (recommended) |
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. 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. If 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. |
Control | 10..1 This element is affected by the following invariants: ele-1 |
Binding | The codes SHOULD be taken from For example codes, see Laboratory Study Typeshttp://hl7.org/fhir/ValueSet/doc-section-codes (preferred to http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab ) |
Type | CodeableConcept(Codeable Concept (IPS)) |
Is Modifier | false |
Requirements | Provides computable standardized labels to topics within the document. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
118. Composition.section:lab-subsections.section.text | |
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. |
Short | Text summary of the section, for human interpretation. |
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
Control | 0..1 This element is affected by the following invariants: cmp-1 |
Type | Narrative |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
120. Composition.section:lab-subsections.section.entry | |
Definition | A reference to the actual resource from which the narrative in the section is derived. |
Short | A reference to data that supports this section |
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
Control | 10..* This element is affected by the following invariants: cmp-2 |
Type | Reference(Observation Results: laboratory, Resource) |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
122. Composition.section:lab-subsections.section.section | |
Definition | A nested sub-section within this section. |
Short | Nested Section |
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. |
Control | 0..0* This element is affected by the following invariants: cmp-1 |
Type | See ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
124. Composition.section:annotations | |
Slice Name | annotations |
Definition | Narrative expression of comments accompanying the report, such as suggestions for evaluation, technical notes from the laboratory, etc. Examples: Suggestion: This result should be evaluated in relation to the patient's medical history and clinical condition. Technical note: A list of accredited examination(s) is available at www.laboratory.com. The root of the sections that make up the composition. |
Short | Annotation commentComposition is broken into sections |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Summary | false |
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists() )cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty() )ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty()) |
126. Composition.section:annotations.modifierExtension | |
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | 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. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
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. 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. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
128. Composition.section:annotations.code | |
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title. |
Short | Classification of section (recommended) |
Comments | 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. If 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. |
Control | 0..1 |
Binding | For example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes (example to http://hl7.org/fhir/ValueSet/doc-section-codes )Classification of a section of a composition/document. |
Type | CodeableConcept |
Is Modifier | false |
Summary | false |
Requirements | Provides computable standardized labels to topics within the document. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
130. Composition.section:annotations.text | |
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. |
Short | Text summary of the section, for human interpretation |
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
Control | 10..1 This element is affected by the following invariants: cmp-1 |
Type | Narrative |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
132. Composition.section:annotations.entry | |
Definition | A reference to the actual resource from which the narrative in the section is derived. |
Short | A reference to data that supports this section |
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
Control | 0..0* This element is affected by the following invariants: cmp-2 |
Type | Reference(Resource) |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
134. Composition.section:annotations.section | |
Definition | A nested sub-section within this section. |
Short | Nested Section |
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. |
Control | 0..0* This element is affected by the following invariants: cmp-1 |
Type | See ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Guidance on how to interpret the contents of this table can be found here
0. Composition | |||||
Definition | Laboratory Report composition. A 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. While 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. | ||||
Short | Laboratory Report composition | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty() )dom-3: 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 ( 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() )dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated ( contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() )dom-5: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty() )dom-6: A resource should have narrative for robust management ( text.`div`.exists() ) | ||||
2. Composition.id | |||||
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
Short | Logical id of this artifact | ||||
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
Control | 0..1 | ||||
Type | id | ||||
Is Modifier | false | ||||
Summary | true | ||||
4. Composition.meta | |||||
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. | ||||
Short | Metadata about the resource | ||||
Control | 0..1 | ||||
Type | Meta | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
6. Composition.implicitRules | |||||
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. | ||||
Short | A set of rules under which this content was created | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true because 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 | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
8. Composition.language | |||||
Definition | The base language in which the resource is written. | ||||
Short | Language of the resource content | ||||
Comments | 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). | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )A human language.
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
10. Composition.text | |||||
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. | ||||
Short | Narrative text | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
12. Composition.contained | |||||
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. | ||||
Short | Contained, inline Resources | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Resource | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
14. Composition.extension | |||||
Definition | An Extension | ||||
Short | Extension | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Composition.extension . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
16. Composition.extension:versionNumber | |||||
Slice Name | versionNumber | ||||
Definition | Version specific identifier for the composition, assigned when each version is created/updated. | ||||
Short | Version-specific identifier for composition | ||||
Comments | While each resource, including the composition itself, has its own version identifier, this is a formal identifier for the logical version of the composition as a whole. It would remain constant if the resources were moved to a new server, and all got new individual resource versions, for example. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Extension(versionNumber) (Extension Type: string) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
18. Composition.extension:basedOn-order-or-requisition | |||||
Slice Name | basedOn-order-or-requisition | ||||
Definition | This extension provides a link to the order [(Reference(ServiceRequest)] or requisition [ServiceRequest.requisition (i.e., 'Request.groupIdentifier')] that this report document is based on and fulfills. | ||||
Short | Document Based On Order | ||||
Control | 0..* | ||||
Type | Extension(Document Based On Order) (Extension Type: Choice of: Identifier, Reference(ServiceRequest)) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
20. Composition.extension:basedOn-order-or-requisition.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
22. Composition.extension:basedOn-order-or-requisition.extension | |||||
Definition | An Extension | ||||
Short | Extension | ||||
Control | 0..0 | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Composition.extension.extension . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
24. Composition.extension:basedOn-order-or-requisition.url | |||||
Definition | Source of the definition for the extension code - a logical name or a URL. | ||||
Short | identifies the meaning of the extension | ||||
Comments | 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. | ||||
Control | 1..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
Fixed Value | http://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition | ||||
26. Composition.extension:basedOn-order-or-requisition.value[x] | |||||
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). | ||||
Short | Value of extension | ||||
Control | 0..1 | ||||
Type | Reference(ServiceRequest) | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on Composition.extension.value[x] . The slices are unordered and Closed, and can be differentiated using the following discriminators: | ||||
28. Composition.extension:basedOn-order-or-requisition.value[x]:valueReference | |||||
Slice Name | valueReference | ||||
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). | ||||
Short | Value of extension | ||||
Control | 0..1 | ||||
Type | Reference(ServiceRequest: Laboratory Order) | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
30. Composition.extension:information-recipient | |||||
Slice Name | information-recipient | ||||
Definition | This extension applies to the Composition resource and is used to represent an intended recipient of the composition. | ||||
Short | Information recipient | ||||
Control | 0..* | ||||
Type | Extension(Information recipient) (Extension Type: Reference(Practitioner, Device, Patient, RelatedPerson, PractitionerRole, Organization)) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
32. Composition.extension:information-recipient.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
34. Composition.extension:information-recipient.extension | |||||
Definition | An Extension | ||||
Short | Extension | ||||
Control | 0..0 | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Composition.extension.extension . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
36. Composition.extension:information-recipient.url | |||||
Definition | Source of the definition for the extension code - a logical name or a URL. | ||||
Short | identifies the meaning of the extension | ||||
Comments | 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. | ||||
Control | 1..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
Fixed Value | http://hl7.eu/fhir/StructureDefinition/information-recipient | ||||
38. Composition.extension:information-recipient.value[x] | |||||
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). | ||||
Short | Value of extension | ||||
Control | 0..1 | ||||
Type | Reference(Practitioner: Laboratory Report, Device, Patient: Person, RelatedPerson, PractitionerRole: Laboratory Report, Organization) | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
40. Composition.extension:diagnosticReport-reference | |||||
Slice Name | diagnosticReport-reference | ||||
Definition | This extension provides a reference to the DiagnosticReport instance that is associated with this Composition. | ||||
Short | Document DiagnosticReport Reference | ||||
Control | 0..1 | ||||
Type | Extension(Document DiagnosticReport Reference) (Extension Type: Reference(DiagnosticReport)) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
42. Composition.extension:diagnosticReport-reference.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
44. Composition.extension:diagnosticReport-reference.extension | |||||
Definition | An Extension | ||||
Short | Extension | ||||
Control | 0..0 | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Composition.extension.extension . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
46. Composition.extension:diagnosticReport-reference.url | |||||
Definition | Source of the definition for the extension code - a logical name or a URL. | ||||
Short | identifies the meaning of the extension | ||||
Comments | 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. | ||||
Control | 1..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
Fixed Value | http://hl7.eu/fhir/laboratory/StructureDefinition/composition-diagnosticReportReference | ||||
48. Composition.extension:diagnosticReport-reference.value[x] | |||||
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). | ||||
Short | Value of extension | ||||
Control | 1..1 | ||||
Type | Reference(DiagnosticReport: Laboratory Report) | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
50. Composition.extension:diagnosticReport-reference.value[x].id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
52. Composition.extension:diagnosticReport-reference.value[x].extension | |||||
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. | ||||
Short | Additional content defined by implementations | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Composition.extension.value[x].extension . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
54. Composition.extension:diagnosticReport-reference.value[x].reference | |||||
Definition | A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. | ||||
Short | Literal reference, Relative, internal or absolute URL | ||||
Comments | Added to the FHIR R4 guide to strctly conform with the R4 rules for document bundle resources inclusion. Using this extension implies to accept a circular reference Composition to/from DiagnosticReport | ||||
Control | 1..1 This element is affected by the following invariants: ref-1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
56. Composition.extension:diagnosticReport-reference.value[x].type | |||||
Definition | The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). | ||||
Short | Type the reference refers to (e.g. "Patient") | ||||
Comments | This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. | ||||
Control | 0..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ResourceType (extensible to http://hl7.org/fhir/ValueSet/resource-types )Aa resource (or, for logical models, the URI of the logical model). | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
58. Composition.extension:diagnosticReport-reference.value[x].identifier | |||||
Definition | An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. | ||||
Short | Logical reference, when literal reference is not known | ||||
Comments | When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..1 | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
60. Composition.extension:diagnosticReport-reference.value[x].display | |||||
Definition | Plain text narrative that identifies the resource in addition to the resource reference. | ||||
Short | Text alternative for the resource | ||||
Comments | This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
62. Composition.modifierExtension | |||||
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Summary | false | ||||
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. | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
64. Composition.identifier | |||||
Definition | Identifiers assigned to this Laboratory Report by the performer or other systems. It shall be common to several report versions | ||||
Short | Report identifier | ||||
Comments | Composition.identifier SHALL be equal to one of the DiagnosticReport.identifier, if at least one exists | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..1 | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
66. Composition.status | |||||
Definition | The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. | ||||
Short | Status of the Report | ||||
Comments | DiagnosticReport.status and Composition.status shall be aligned, based on the http://hl7.eu/fhir/laboratory/ConceptMap/ConceptMap-eu-diagRptStatus2CompStatus mapping | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from CompositionStatus (required to http://hl7.org/fhir/ValueSet/composition-status|4.0.1 )The workflow/clinical status of the composition. | ||||
Type | code | ||||
Is Modifier | true because 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 | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | Need to be able to mark interim, amended, or withdrawn compositions or documents. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
68. Composition.type | |||||
Definition | Specifies that it refers to a Laboratory Report | ||||
Short | Type of (Laboratory) Report | ||||
Comments | At least one DiagnosticReport.code.coding and Composition.type.coding SHALL be equal | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHOULD be taken from Laboratory Report Types (preferred to http://hl7.eu/fhir/laboratory/ValueSet/lab-reportType-eu-lab ) | ||||
Type | CodeableConcept(Codeable Concept (IPS)) | ||||
Is Modifier | false | ||||
Requirements | Key metadata element describing the composition, used in searching/filtering. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
70. Composition.category | |||||
Definition | A code that classifies this laboratory report. Two basic categories has been selected in this guide: laboratory specialty and Study type. Laboratory specialty is characteristic of the laboratory that produced the test result while Study type is an arbitrary classificion of the test type. | ||||
Short | Report Category | ||||
Comments | DiagnosticReport.category and Composition.category shall be aligned | ||||
Control | 0..* | ||||
Binding | For example codes, see DocumentClassValueSet (example to http://hl7.org/fhir/ValueSet/document-classcodes )High-level kind of a clinical document at a macro level. | ||||
Type | CodeableConcept(Codeable Concept (IPS)) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on Composition.category . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
72. Composition.category:studyType | |||||
Slice Name | studyType | ||||
Definition | Laboratory services, i.e., results of tests performed, could be characterized using typology of services, commonly called study types. Study type could be seen as an attribute or grouping mechanism that assigns a common clinical sense to certain types of laboratory test results., e.g., Hemoglobin, Platelet count, etc. belongs to 'Hematology study'. | ||||
Short | The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) | ||||
Comments | In comparison to the laboratory specialty which is an attribute of laboratory, study type is a categorization of laboratory service. It needs to be mentioned that classification of test to study types in not standardized. | ||||
Control | 0..* | ||||
Binding | The codes SHALL be taken from Laboratory Study Types (required to http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
74. Composition.category:specialty | |||||
Slice Name | specialty | ||||
Definition | Laboratory specialty is an attribute of any laboratory setting representing professional qualification of the laboratory to execute certain kind of laboratory tests. | ||||
Short | The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry) | ||||
Comments | Specialty could be used as parameter for searching/querying of laboratory test results. | ||||
Control | 0..* | ||||
Binding | The codes SHALL be taken from Laboratory Specialty (required to http://hl7.eu/fhir/laboratory/ValueSet/lab-specialty-eu-lab ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
76. Composition.subject | |||||
Definition | Who or what this report is about. The report can be about a human patient, a living subject, a device (e.g. a machine), a location 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). | ||||
Short | Who and/or what this report is about | ||||
Comments | DiagnosticReport and Composition SHALL have the same subject | ||||
Control | 1..1 | ||||
Type | Reference(Patient: Person, Patient: Animal, Group, Location, Device) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
78. Composition.encounter | |||||
Definition | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. | ||||
Short | The healthcare event which this Laboratory Report is about (when test ordered). | ||||
Comments | This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). DiagnosticReport and Composition SHALL have the same encounter. | ||||
Control | 0..1 | ||||
Type | Reference(Encounter) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Provides context for the composition and supports searching. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
80. Composition.date | |||||
Definition | The composition editing time, when the composition was last logically changed by the author. | ||||
Short | Composition editing time | ||||
Comments | The Last Modified Date on the composition may be after the date of the document was attested without being changed. | ||||
Control | 1..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
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 is the date of packaging. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
82. Composition.author | |||||
Definition | Identifies who is responsible for the information in the Laboratory Report, not necessarily who typed it in. | ||||
Short | Who and/or what authored the Laboratory Report | ||||
Comments | If a DiagnosticReport.resultsInterpreter exists this is expected to be a Composition.author; otherwise a DiagnosticReport.performer should be an author. | ||||
Control | 1..* | ||||
Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Identifies who is responsible for the content. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
84. Composition.title | |||||
Definition | Official human-readable label for the composition. For this document should be "Laboratory Report" or any equivalent translation | ||||
Short | Laboratory Report | ||||
Comments | 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. | ||||
Control | 1..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
86. Composition.confidentiality | |||||
Definition | The code specifying the level of confidentiality of the Composition. | ||||
Short | As defined by affinity domain | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from v3.ConfidentialityClassification (2014-03-26) (required to http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 )Codes specifying the level of confidentiality of the composition. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
88. Composition.attester | |||||
Definition | A participant who has attested to the accuracy of the composition/document. | ||||
Short | Attests the report accuracy | ||||
Comments | Only list each attester once. | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Identifies responsibility for the accuracy of the composition content. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
90. Composition.attester.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
92. Composition.attester.extension | |||||
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. | ||||
Short | Additional content defined by implementations | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
94. Composition.attester.modifierExtension | |||||
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
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. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
96. Composition.attester.mode | |||||
Definition | The type of attestation the authenticator offers. | ||||
Short | The type of attestation | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from CompositionAttestationMode (required to http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 )The way in which a person authenticated a composition. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Indicates the level of authority of the attestation. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
98. Composition.attester.time | |||||
Definition | When the composition was attested by the party. | ||||
Short | When the report was attested by the party | ||||
Control | 0..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Identifies when the information in the composition was deemed accurate. (Things may have changed since then.). | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
100. Composition.attester.party | |||||
Definition | Who attested the composition in the specified way. | ||||
Short | Who attested the report | ||||
Comments | For a Laboratory Report it is usually non expected that the attester would be a Patient or a RealtedPerson | ||||
Control | 0..1 | ||||
Type | Reference(Patient, RelatedPerson, Practitioner, PractitionerRole, Organization) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Identifies who has taken on the responsibility for accuracy of the composition content. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
102. Composition.custodian | |||||
Definition | Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. | ||||
Short | Organization which maintains the composition | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Type | Reference(Organization) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Identifies where to go to find the current version, where to report issues, etc. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
104. Composition.relatesTo | |||||
Definition | Relationships that this composition has with other compositions or documents that already exist. | ||||
Short | Relationships to other compositions/documents | ||||
Comments | A document is a version specific composition. | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
106. Composition.relatesTo.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
108. Composition.relatesTo.extension | |||||
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. | ||||
Short | Additional content defined by implementations | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
110. Composition.relatesTo.modifierExtension | |||||
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
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. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
112. Composition.relatesTo.code | |||||
Definition | The type of relationship that this composition has with anther composition or document. | ||||
Short | replaces | transforms | signs | appends | ||||
Comments | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from DocumentRelationshipType (required to http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 )The type of relationship between documents. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
114. Composition.relatesTo.target[x] | |||||
Definition | The target composition/document of this relationship. | ||||
Short | Target of the relationship | ||||
Control | 1..1 | ||||
Type | Choice of: Identifier, Reference(Composition) | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
116. Composition.event | |||||
Definition | The clinical service, such as a colonoscopy or an appendectomy, being documented. | ||||
Short | The laboratory service(s) being documented | ||||
Comments | The event needs to be consistent with the type element, though can provide further information if desired. | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
118. Composition.event.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
120. Composition.event.extension | |||||
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. | ||||
Short | Additional content defined by implementations | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
122. Composition.event.modifierExtension | |||||
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
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. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
124. Composition.event.code | |||||
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. | ||||
Short | Code(s) that apply to the laboratory service(s) being documented | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Binding | For example codes, see v3 Code System ActCode (example to http://terminology.hl7.org/ValueSet/v3-ActCode )This list of codes represents the main clinical acts being documented. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
126. Composition.event.period | |||||
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. | ||||
Short | Period of time covered by the documentation | ||||
Control | 0..1 | ||||
Type | Period | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
128. Composition.event.detail | |||||
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. | ||||
Short | The laboratory service(s) being documented | ||||
Control | 0..* | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
130. Composition.section | |||||
Definition | The "body" of the report is organized as a tree of up to two levels of sections: top level sections represent laboratory specialties. A top level section SHALL contain either one text block carrying all the text results produced for this specialty along with Laboratory Data Entries or a set of Laboratory Report Item Sections. In the first case the specialty section happens to also be a leaf section. In the latter case, each (second level) leaf section contained in the (top level) specialty section represents a Report Item: i.e., a battery, a specimen study (especially in microbiology), or an individual test. In addition, any leaf section SHALL contain a Laboratory Data Entries containing the observations of that section in a machine-readable format. | ||||
Short | Composition is broken into sections | ||||
Control | 1..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists() )cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty() )ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on Composition.section . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
132. Composition.section.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
134. Composition.section.extension | |||||
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. | ||||
Short | Additional content defined by implementations | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
136. Composition.section.modifierExtension | |||||
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
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. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
138. Composition.section.title | |||||
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. | ||||
Short | Label for section (e.g. for ToC) | ||||
Comments | 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. | ||||
Control | 1..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
Alternate Names | header, label, caption | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
140. Composition.section.code | |||||
Definition | A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. | ||||
Short | Concept - reference to a terminology or just text | ||||
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes )Classification of a section of a composition/document. | ||||
Type | CodeableConcept(Codeable Concept (IPS)) | ||||
Is Modifier | false | ||||
Requirements | Provides computable standardized labels to topics within the document. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
142. Composition.section.author | |||||
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
Short | Who and/or what authored the section | ||||
Control | 0..* | ||||
Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Identifies who is responsible for the content. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
144. Composition.section.focus | |||||
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). | ||||
Short | Who/what the section is about, when it is not about the subject of composition | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
146. Composition.section.text | |||||
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. | ||||
Short | Text summary of the section, for human interpretation | ||||
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
Control | 0..1 This element is affected by the following invariants: cmp-1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
148. Composition.section.mode | |||||
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. | ||||
Short | working | snapshot | changes | ||||
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1 )The processing mode that applies to this section. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
150. Composition.section.orderedBy | |||||
Definition | Specifies the order applied to the items in the section entries. | ||||
Short | Order of section entries | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order )What order applies to the items in the entry. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
152. Composition.section.entry | |||||
Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
Short | A reference to data that supports this section | ||||
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
Control | 0..* This element is affected by the following invariants: cmp-2 | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
154. Composition.section.emptyReason | |||||
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
Short | Why the section is empty | ||||
Comments | 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. | ||||
Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason )If a section is empty, why it is empty. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
156. Composition.section.section | |||||
Definition | A nested sub-section within this section. | ||||
Short | Nested Section | ||||
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
Type | See ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
158. Composition.section:lab-no-subsections | |||||
Slice Name | lab-no-subsections | ||||
Definition | Variant 1: With this option, all laboratory report data entries are provided in the top level sections and no sub-sections are allowed. | ||||
Short | Variant 1: EU Laboratory Report section with entries and no sub-sections | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists() )cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty() )ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count()) ) | ||||
160. Composition.section:lab-no-subsections.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
162. Composition.section:lab-no-subsections.extension | |||||
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. | ||||
Short | Additional content defined by implementations | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
164. Composition.section:lab-no-subsections.modifierExtension | |||||
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
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. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
166. Composition.section:lab-no-subsections.title | |||||
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. | ||||
Short | Label for section (e.g. for ToC) | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
Alternate Names | header, label, caption | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
168. Composition.section:lab-no-subsections.code | |||||
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title. | ||||
Short | Classification of section (recommended) | ||||
Comments | 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. If 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. | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from Laboratory Study Types (preferred to http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Provides computable standardized labels to topics within the document. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
170. Composition.section:lab-no-subsections.author | |||||
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
Short | Who and/or what authored the section | ||||
Control | 0..* | ||||
Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Identifies who is responsible for the content. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
172. Composition.section:lab-no-subsections.focus | |||||
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). | ||||
Short | Who/what the section is about, when it is not about the subject of composition | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
174. Composition.section:lab-no-subsections.text | |||||
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. | ||||
Short | Text summary of the section, for human interpretation. | ||||
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
Control | 0..1 This element is affected by the following invariants: cmp-1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
176. Composition.section:lab-no-subsections.mode | |||||
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. | ||||
Short | working | snapshot | changes | ||||
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1 )The processing mode that applies to this section. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
178. Composition.section:lab-no-subsections.orderedBy | |||||
Definition | Specifies the order applied to the items in the section entries. | ||||
Short | Order of section entries | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order )What order applies to the items in the entry. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
180. Composition.section:lab-no-subsections.entry | |||||
Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
Short | A reference to data that supports this section | ||||
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
Control | 1..* This element is affected by the following invariants: cmp-2 | ||||
Type | Reference(Observation Results: laboratory) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
182. Composition.section:lab-no-subsections.emptyReason | |||||
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
Short | Why the section is empty | ||||
Comments | 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. | ||||
Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason )If a section is empty, why it is empty. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
184. Composition.section:lab-no-subsections.section | |||||
Definition | A nested sub-section within this section. | ||||
Short | Nested Section | ||||
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
Control | 0..0 This element is affected by the following invariants: cmp-1 | ||||
Type | See ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
186. Composition.section:lab-subsections | |||||
Slice Name | lab-subsections | ||||
Definition | Variant 2: With this option, this top level section doesn't include NEITHER a top level text NOR entry elements. Each Report Item is contained in a corresponding sub-sections which contains the Lab Report Data Entry. | ||||
Short | Variant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists() )cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty() )ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count()) ) | ||||
188. Composition.section:lab-subsections.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
190. Composition.section:lab-subsections.extension | |||||
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. | ||||
Short | Additional content defined by implementations | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
192. Composition.section:lab-subsections.modifierExtension | |||||
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
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. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
194. Composition.section:lab-subsections.title | |||||
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. | ||||
Short | Label for section (e.g. for ToC) | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
Alternate Names | header, label, caption | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
196. Composition.section:lab-subsections.code | |||||
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title. | ||||
Short | Classification of section (recommended) | ||||
Comments | 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. If 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. | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from Laboratory Study Types (preferred to http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Provides computable standardized labels to topics within the document. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
198. Composition.section:lab-subsections.author | |||||
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
Short | Who and/or what authored the section | ||||
Control | 0..* | ||||
Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Identifies who is responsible for the content. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
200. Composition.section:lab-subsections.focus | |||||
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). | ||||
Short | Who/what the section is about, when it is not about the subject of composition | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
202. Composition.section:lab-subsections.text | |||||
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. | ||||
Short | Text summary of the section, for human interpretation | ||||
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
Control | 0..0 This element is affected by the following invariants: cmp-1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
204. Composition.section:lab-subsections.mode | |||||
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. | ||||
Short | working | snapshot | changes | ||||
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1 )The processing mode that applies to this section. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
206. Composition.section:lab-subsections.orderedBy | |||||
Definition | Specifies the order applied to the items in the section entries. | ||||
Short | Order of section entries | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order )What order applies to the items in the entry. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
208. Composition.section:lab-subsections.entry | |||||
Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
Short | A reference to data that supports this section | ||||
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
Control | 0..0 This element is affected by the following invariants: cmp-2 | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
210. Composition.section:lab-subsections.emptyReason | |||||
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
Short | Why the section is empty | ||||
Comments | 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. | ||||
Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason )If a section is empty, why it is empty. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
212. Composition.section:lab-subsections.section | |||||
Definition | A nested sub-section within this section. | ||||
Short | Nested Section | ||||
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
Control | 1..* This element is affected by the following invariants: cmp-1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
214. Composition.section:lab-subsections.section.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
216. Composition.section:lab-subsections.section.extension | |||||
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. | ||||
Short | Additional content defined by implementations | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
218. Composition.section:lab-subsections.section.modifierExtension | |||||
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
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. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
220. Composition.section:lab-subsections.section.title | |||||
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. | ||||
Short | Label for section (e.g. for ToC) | ||||
Comments | 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. | ||||
Control | 1..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
Alternate Names | header, label, caption | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
222. Composition.section:lab-subsections.section.code | |||||
Definition | A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. | ||||
Short | Concept - reference to a terminology or just text | ||||
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHOULD be taken from Laboratory Study Types (preferred to http://hl7.eu/fhir/laboratory/ValueSet/lab-studyType-eu-lab ) | ||||
Type | CodeableConcept(Codeable Concept (IPS)) | ||||
Is Modifier | false | ||||
Requirements | Provides computable standardized labels to topics within the document. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
224. Composition.section:lab-subsections.section.author | |||||
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
Short | Who and/or what authored the section | ||||
Control | 0..* | ||||
Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Identifies who is responsible for the content. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
226. Composition.section:lab-subsections.section.focus | |||||
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). | ||||
Short | Who/what the section is about, when it is not about the subject of composition | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
228. Composition.section:lab-subsections.section.text | |||||
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. | ||||
Short | Text summary of the section, for human interpretation. | ||||
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
Control | 0..1 This element is affected by the following invariants: cmp-1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
230. Composition.section:lab-subsections.section.mode | |||||
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. | ||||
Short | working | snapshot | changes | ||||
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1 )The processing mode that applies to this section. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
232. Composition.section:lab-subsections.section.orderedBy | |||||
Definition | Specifies the order applied to the items in the section entries. | ||||
Short | Order of section entries | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order )What order applies to the items in the entry. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
234. Composition.section:lab-subsections.section.entry | |||||
Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
Short | A reference to data that supports this section | ||||
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
Control | 1..* This element is affected by the following invariants: cmp-2 | ||||
Type | Reference(Observation Results: laboratory) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
236. Composition.section:lab-subsections.section.emptyReason | |||||
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
Short | Why the section is empty | ||||
Comments | 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. | ||||
Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason )If a section is empty, why it is empty. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
238. Composition.section:lab-subsections.section.section | |||||
Definition | A nested sub-section within this section. | ||||
Short | Nested Section | ||||
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
Control | 0..0 This element is affected by the following invariants: cmp-1 | ||||
Type | See ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
240. Composition.section:annotations | |||||
Slice Name | annotations | ||||
Definition | Narrative expression of comments accompanying the report, such as suggestions for evaluation, technical notes from the laboratory, etc. Examples: Suggestion: This result should be evaluated in relation to the patient's medical history and clinical condition. Technical note: A list of accredited examination(s) is available at www.laboratory.com. | ||||
Short | Annotation comment | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists() )cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty() )ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count()) ) | ||||
242. Composition.section:annotations.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
244. Composition.section:annotations.extension | |||||
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. | ||||
Short | Additional content defined by implementations | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
246. Composition.section:annotations.modifierExtension | |||||
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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
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. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
248. Composition.section:annotations.title | |||||
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. | ||||
Short | Label for section (e.g. for ToC) | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
Alternate Names | header, label, caption | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
250. Composition.section:annotations.code | |||||
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title. | ||||
Short | Classification of section (recommended) | ||||
Comments | 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. If 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. | ||||
Control | 0..1 | ||||
Binding | For example codes, see DocumentSectionCodes (example to http://hl7.org/fhir/ValueSet/doc-section-codes )Classification of a section of a composition/document. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Provides computable standardized labels to topics within the document. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
252. Composition.section:annotations.author | |||||
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
Short | Who and/or what authored the section | ||||
Control | 0..* | ||||
Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Identifies who is responsible for the content. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
254. Composition.section:annotations.focus | |||||
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). | ||||
Short | Who/what the section is about, when it is not about the subject of composition | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
256. Composition.section:annotations.text | |||||
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. | ||||
Short | Text summary of the section, for human interpretation | ||||
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
Control | 1..1 This element is affected by the following invariants: cmp-1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
258. Composition.section:annotations.mode | |||||
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. | ||||
Short | working | snapshot | changes | ||||
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1 )The processing mode that applies to this section. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
260. Composition.section:annotations.orderedBy | |||||
Definition | Specifies the order applied to the items in the section entries. | ||||
Short | Order of section entries | ||||
Comments | 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. | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order )What order applies to the items in the entry. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
262. Composition.section:annotations.entry | |||||
Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
Short | A reference to data that supports this section | ||||
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
Control | 0..0 This element is affected by the following invariants: cmp-2 | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
264. Composition.section:annotations.emptyReason | |||||
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
Short | Why the section is empty | ||||
Comments | 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. | ||||
Control | 0..1 This element is affected by the following invariants: cmp-2 | ||||
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason )If a section is empty, why it is empty. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
266. Composition.section:annotations.section | |||||
Definition | A nested sub-section within this section. | ||||
Short | Nested Section | ||||
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
Control | 0..0 This element is affected by the following invariants: cmp-1 | ||||
Type | See ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) |