GP Connect - Emergency Supply of Medications (ITK3)

Part of the GP Connect product family
Note: This specification was originally titled "Digital Medicines (DigiMeds)" and maintained by the PODAC Programme.

Profile: CareConnect-ITK-DM-EmergencySupply-Composition-1

idΣ0..1id
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
textC0..1Narrative
contained0..*Resource
careSettingTypeExtensionC1..1Extension(CodeableConcept)
modifierExtension?! C0..*Extension
id0..1string
extensionC0..*Extension
useΣ ?!0..0codeBinding
typeΣ0..0CodeableConceptBinding
systemΣ1..1uri
valueΣ1..1string
periodΣ C0..0Period
assignerΣ C0..0Reference(CareConnect-Organization-1)
statusΣ ?!1..1codeBinding
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uri
versionΣ0..0string
codeΣ1..1code
displayΣ1..1string
userSelectedΣ0..0boolean
textΣ0..1string
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uri
versionΣ0..0string
codeΣ1..1code
displayΣ1..1string
userSelectedΣ0..0boolean
textΣ0..1string
id0..1string
extensionC0..*Extension
referenceΣ C1..1string
identifierΣ0..1Identifier
displayΣ0..1string
id0..1string
extensionC0..*Extension
referenceΣ C1..1string
identifierΣ0..1Identifier
displayΣ0..1string
dateΣ1..1dateTime
id0..1string
extensionC0..*Extension
referenceΣ C1..1string
identifierΣ0..1Identifier
displayΣ0..1string
titleΣ1..1string
confidentialityΣ ?!0..0codeBinding
id0..1string
extensionC0..*Extension
referenceΣ C1..1string
identifierΣ0..1Identifier
displayΣ0..1string
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
codeΣ1..1codeBindingFixed Value
targetIdentifierIdentifier
targetReferenceReference(CareConnect-ITK-DM-Immunization-Composition-1)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
title0..1string
code0..1CodeableConceptBinding
textC0..1Narrative
modeΣ ?!0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryC0..*Reference(Resource)
emptyReasonC0..1CodeableConceptBinding
sectionC0..*see (section)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
title1..1string
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..0string
codeΣ1..1codeFixed Value
displayΣ1..1stringFixed Value
userSelectedΣ0..0boolean
textΣ0..0string
textC1..1Narrative
modeΣ ?!0..0codeBinding
orderedBy0..0CodeableConceptBinding
entryC0..*Reference(CareConnect-ITK-Allergy-List-1 | ITK-Attachment-Binary-1)
emptyReasonC0..0CodeableConceptBinding
sectionC0..*see (section)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
title1..1stringFixed Value
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..0string
codeΣ1..1codeFixed Value
displayΣ1..1stringFixed Value
userSelectedΣ0..0boolean
textΣ0..0string
textC1..1Narrative
modeΣ ?!0..0codeBinding
orderedBy0..0CodeableConceptBinding
id0..1string
extensionC0..*Extension
referenceΣ C1..1string
identifierΣ0..1Identifier
displayΣ0..1string
emptyReasonC0..0CodeableConceptBinding
sectionC0..0see (section)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
title1..1stringFixed Value
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..0string
codeΣ1..1codeFixed Value
displayΣ1..1stringFixed Value
userSelectedΣ0..0boolean
textΣ0..0string
textC1..1Narrative
modeΣ ?!0..0codeBinding
orderedBy0..0CodeableConceptBinding
entryC0..0Reference(Resource)
emptyReasonC0..0CodeableConceptBinding
sectionC0..0see (section)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
title1..1stringFixed Value
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..0string
codeΣ1..1codeFixed Value
displayΣ1..1stringFixed Value
userSelectedΣ0..0boolean
textΣ0..0string
textC1..1Narrative
modeΣ ?!0..0codeBinding
orderedBy0..0CodeableConceptBinding
id0..1string
extensionC0..*Extension
referenceΣ C1..1string
identifierΣ0..1Identifier
displayΣ0..1string
emptyReasonC0..0CodeableConceptBinding
sectionC0..0see (section)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
title1..1stringFixed Value
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..0string
codeΣ1..1codeFixed Value
displayΣ1..1stringFixed Value
userSelectedΣ0..0boolean
textΣ0..0string
textC1..1Narrative
modeΣ ?!0..0codeBinding
orderedBy0..0CodeableConceptBinding
id0..1string
extensionC0..*Extension
referenceΣ C1..1string
identifierΣ0..1Identifier
displayΣ0..1string
emptyReasonC0..0CodeableConceptBinding
sectionC0..0see (section)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
title1..1stringFixed Value
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..0string
codeΣ1..1codeFixed Value
displayΣ1..1stringFixed Value
userSelectedΣ0..0boolean
textΣ0..0string
textC1..1Narrative
modeΣ ?!0..0codeBinding
orderedBy0..0CodeableConceptBinding
entryC0..0Reference(Resource)
emptyReasonC0..0CodeableConceptBinding
sectionC0..0see (section)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
title1..1stringFixed Value
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..0string
codeΣ1..1codeFixed Value
displayΣ1..1stringFixed Value
userSelectedΣ0..0boolean
textΣ0..0string
textC1..1Narrative
modeΣ ?!0..0codeBinding
orderedBy0..0CodeableConceptBinding
entryC0..0Reference(Resource)
emptyReasonC0..0CodeableConceptBinding
sectionC0..0see (section)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
title1..1stringFixed Value
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..0string
codeΣ1..1codeFixed Value
displayΣ1..1stringFixed Value
userSelectedΣ0..0boolean
textΣ0..0string
textC1..1Narrative
modeΣ ?!0..0codeBinding
orderedBy0..0CodeableConceptBinding
id0..1string
extensionC0..*Extension
referenceΣ C1..1string
identifierΣ0..1Identifier
displayΣ0..1string
emptyReasonC0..0CodeableConceptBinding
sectionC0..0see (section)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
title1..1stringFixed Value
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..0string
codeΣ1..1codeFixed Value
displayΣ1..1stringFixed Value
userSelectedΣ0..0boolean
textΣ0..0string
textC1..1Narrative
modeΣ ?!0..0codeBinding
orderedBy0..0CodeableConceptBinding
id0..1string
extensionC0..*Extension
referenceΣ C1..1string
identifierΣ0..1Identifier
displayΣ0..1string
emptyReasonC0..0CodeableConceptBinding
sectionC0..0see (section)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
title1..1stringFixed Value
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..0string
codeΣ1..1codeFixed Value
displayΣ1..1stringFixed Value
userSelectedΣ0..0boolean
textΣ0..0string
textC1..1Narrative
modeΣ ?!0..0codeBinding
orderedBy0..0CodeableConceptBinding
entryC0..0Reference(Resource)
emptyReasonC0..0CodeableConceptBinding
sectionC0..0see (section)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
title1..1string
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..0string
codeΣ1..1codeFixed Value
displayΣ1..1stringFixed Value
userSelectedΣ0..0boolean
textΣ0..1string
textC1..1Narrative
modeΣ ?!0..0codeBinding
orderedBy0..0CodeableConceptBinding
emptyReasonC0..0CodeableConceptBinding
sectionC0..0see (section)
Composition
ShortA set of resources composed into a single coherent clinical statement with clinical attestation
Definition

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.

Cardinality0..*
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.

Constraints
  • dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
    contained.contained.empty()
  • dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative
    contained.text.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-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
    contained.where(('#'+id in %resource.descendants().reference).not()).empty()
Mappings
  • rim: Entity. Role, or Act
  • rim: Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
  • cda: ClinicalDocument
  • w5: infrastructure.documents
Composition.id
ShortLogical id of this artifact
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Cardinality0..1
Typeid
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.meta
ShortMetadata about the resource
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

Cardinality0..1
TypeMeta
SummaryTrue
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.implicitRules
ShortA set of rules under which this content was created
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.

Cardinality0..1
Typeuri
ModifierTrue
SummaryTrue
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.

This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.language
ShortLanguage of the resource content
Definition

The base language in which the resource is written.

Cardinality0..1
Typecode
Binding

A human language.

Common Languages (extensible)

Binding extensions
maxValueSetAll Languages
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).

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.text
ShortText summary of the resource, for human interpretation
Definition

A human-readable narrative that contains a summary of the resource, and may 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.

Cardinality0..1
TypeNarrative
Aliasnarrative, html, xhtml, display
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 in formation is added later.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, dom-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: Act.text?
Composition.contained
ShortContained, inline Resources
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.

Cardinality0..*
TypeResource
Aliasinline resources, anonymous resources, contained 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.

Mappings
  • rim: Entity. Role, or Act
  • rim: N/A
Composition.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the resource. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.extension:careSettingTypeExtension
ShortAn extension to carry the Care setting type of the document
Definition

Optional Extension Element - found in all resources.

Cardinality1..1
TypeExtension(CodeableConcept)
Aliasextensions, user content
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.modifierExtension
ShortExtensions that cannot be ignored
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. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.identifier
ShortLogical identifier of composition (version-independent)
Definition

Logical identifier for the composition, assigned when created. This identifier stays constant as the composition is changed over time.

Cardinality1..1
TypeIdentifier
SummaryTrue
Comments

See discussion in resource definition for how these relate.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • rim: Document.id / Document.setId
  • cda: .setId
  • w5: id
Composition.identifier.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.identifier.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.identifier.use
Shortusual | official | temp | secondary (If known)
Definition

The purpose of this identifier.

Cardinality0..0
Typecode
Binding

Identifies the purpose for this identifier, if known .

IdentifierUse (required)

ModifierTrue
SummaryTrue
Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Comments

This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: N/A
  • rim: Role.code or implied by context
Composition.identifier.type
ShortDescription of identifier
Definition

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

Cardinality0..0
TypeCodeableConcept
Binding

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

Identifier Type Codes (extensible)

SummaryTrue
Requirements

Allows users to make use of identifiers when the identifier system is not known.

Comments

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage.

Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • v2: CX.5
  • rim: Role.code or implied by context
Composition.identifier.system
ShortThe namespace for the identifier value
Definition

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Comments

see http://en.wikipedia.org/wiki/Uniform_resource_identifier

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
ExamplesGeneral
http://www.acme.com/identifiers/patient
Mappings
  • rim: n/a
  • v2: CX.4 / EI-2-4
  • rim: II.root or Role.id.root
  • servd: ./IdentifierType
Composition.identifier.value
ShortContains a UUID
Definition

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

Cardinality1..1
Typestring
SummaryTrue
Comments

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
ExamplesGeneral
123456
Mappings
  • rim: n/a
  • v2: CX.1 / EI.1
  • rim: II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
  • servd: ./Value
Composition.identifier.period
ShortTime period when id is/was valid for use
Definition

Time period during which identifier is/was valid for use.

Cardinality0..0
TypePeriod
SummaryTrue
Comments

This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval|Duration.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • per-1: If present, start SHALL have a lower value than end
    start.empty() or end.empty() or (start <= end)
Mappings
  • rim: n/a
  • v2: DR
  • rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
  • v2: CX.7 + CX.8
  • rim: Role.effectiveTime or implied by context
  • servd: ./StartDate and ./EndDate
Composition.identifier.assigner
ShortOrganization that issued id (may be just text)
Definition

Organization that issued/manages the identifier.

Cardinality0..0
TypeReference(CareConnect-Organization-1)
SummaryTrue
Comments

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • v2: CX.4 / (CX.4,CX.9,CX.10)
  • rim: II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
  • servd: ./IdentifierIssuingAuthority
Composition.status
Shortpreliminary | final | amended | entered-in-error
Definition

The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.

Cardinality1..1
Typecode
Binding

The workflow/clinical status of the composition.

CompositionStatus (required)

ModifierTrue
SummaryTrue
Requirements

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Comments

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
  • cda: n/a
  • w5: status
Composition.type
ShortKind of composition
Definition

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.

Cardinality1..1
TypeCodeableConcept
Binding

A set of codes to classify the type of document.

Document Type (preferred)

SummaryTrue
Requirements

Key metadata element describing the composition, used in searching/filtering.

Comments

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
  • w5: class
Composition.type.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.type.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.type.coding
ShortCode defined by a terminology system
Definition

A reference to a code defined by a terminology system.

Cardinality0..*
TypeCoding
SummaryTrue
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
  • rim: CV
  • orim: fhir:Coding rdfs:subClassOf dt:CDCoding
  • v2: C*E.1-8, C*E.10-22
  • rim: union(., ./translation)
  • orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Composition.type.coding.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.type.coding.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.type.coding.system
ShortIdentity of the terminology system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.3
  • rim: ./codeSystem
  • orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Composition.type.coding.version
ShortVersion of the system - if relevant
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Cardinality0..0
Typestring
SummaryTrue
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.7
  • rim: ./codeSystemVersion
  • orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Composition.type.coding.code
ShortSymbol in syntax defined by the system
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Cardinality1..1
Typecode
SummaryTrue
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.1
  • rim: ./code
  • orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Composition.type.coding.display
ShortRepresentation defined by the system
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Cardinality1..1
Typestring
SummaryTrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.2 - but note this is not well followed
  • rim: CV.displayName
  • orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Composition.type.coding.userSelected
ShortIf this coding was chosen directly by the user
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Cardinality0..0
Typeboolean
SummaryTrue
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: Sometimes implied by being first
  • rim: CD.codingRationale
  • orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Composition.type.text
ShortPlain text representation of the concept
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Cardinality0..1
Typestring
SummaryTrue
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.9. But note many systems use C*E.2 for this
  • rim: ./originalText[mediaType/code="text/plain"]/data
  • orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Composition.class
ShortCategorization of Composition
Definition

A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

Cardinality0..1
TypeCodeableConcept
Binding

High-level kind of a clinical document at a macro level.

FHIR Document Class Codes (example)

SummaryTrue
Requirements

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Comments

This is a metadata field from XDS/MHD.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
  • cda: n/a
  • w5: class
Composition.class.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.class.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.class.coding
ShortCode defined by a terminology system
Definition

A reference to a code defined by a terminology system.

Cardinality0..*
TypeCoding
SummaryTrue
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
  • rim: CV
  • orim: fhir:Coding rdfs:subClassOf dt:CDCoding
  • v2: C*E.1-8, C*E.10-22
  • rim: union(., ./translation)
  • orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Composition.class.coding.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.class.coding.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.class.coding.system
ShortIdentity of the terminology system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.3
  • rim: ./codeSystem
  • orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Composition.class.coding.version
ShortVersion of the system - if relevant
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Cardinality0..0
Typestring
SummaryTrue
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.7
  • rim: ./codeSystemVersion
  • orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Composition.class.coding.code
ShortSymbol in syntax defined by the system
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Cardinality1..1
Typecode
SummaryTrue
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.1
  • rim: ./code
  • orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Composition.class.coding.display
ShortRepresentation defined by the system
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Cardinality1..1
Typestring
SummaryTrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.2 - but note this is not well followed
  • rim: CV.displayName
  • orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Composition.class.coding.userSelected
ShortIf this coding was chosen directly by the user
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Cardinality0..0
Typeboolean
SummaryTrue
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: Sometimes implied by being first
  • rim: CD.codingRationale
  • orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Composition.class.text
ShortPlain text representation of the concept
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Cardinality0..1
Typestring
SummaryTrue
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.9. But note many systems use C*E.2 for this
  • rim: ./originalText[mediaType/code="text/plain"]/data
  • orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Composition.subject
ShortWho and/or what the composition is about
Definition

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).

Cardinality1..1
TypeReference(CareConnect-Patient-1)
SummaryTrue
Requirements

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

Comments

For clinical documents, this is usually the patient.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .participation[typeCode="SBJ"].role[typeCode="PAT"]
  • cda: .recordTarget
  • w5: who.focus
Composition.subject.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.subject.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.subject.reference
ShortLiteral reference, Relative, internal or absolute URL
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.

Cardinality1..1
Typestring
SummaryTrue
Comments

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, ref-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.subject.identifier
ShortLogical reference, when literal reference is not known
Definition

An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity 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.

Cardinality0..1
TypeIdentifier
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • rim: .identifier
Composition.subject.display
ShortText alternative for the resource
Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Cardinality0..1
Typestring
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.encounter
ShortContext of the Composition
Definition

Describes the clinical encounter or type of care this documentation is associated with.

Cardinality0..1
TypeReference(CareConnect-ITK-Encounter-1)
Must SupportTrue
SummaryTrue
Requirements

Provides context for the composition and supports searching.

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
  • cda: .componentOf.encompassingEncounter
  • w5: context
Composition.encounter.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.encounter.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.encounter.reference
ShortLiteral reference, Relative, internal or absolute URL
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.

Cardinality1..1
Typestring
SummaryTrue
Comments

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, ref-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.encounter.identifier
ShortLogical reference, when literal reference is not known
Definition

An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity 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.

Cardinality0..1
TypeIdentifier
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • rim: .identifier
Composition.encounter.display
ShortText alternative for the resource
Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Cardinality0..1
Typestring
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.date
ShortComposition editing time
Definition

The composition editing time, when the composition was last logically changed by the author.

Cardinality1..1
TypedateTime
SummaryTrue
Requirements

dateTime is used for tracking, organizing versions and searching.

Comments

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .effectiveTime[type="TS"]
  • cda: .effectiveTime
  • w5: when.done
Composition.author
ShortWho and/or what authored the composition
Definition

Identifies who is responsible for the information in the composition, not necessarily who typed it in.

Cardinality1..*
TypeReference(CareConnect-Practitioner-1 | ITK-Device-1)
SummaryTrue
Requirements

Identifies who is responsible for the content.

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
  • cda: .author.assignedAuthor
  • w5: who.author
Composition.author.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.author.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.author.reference
ShortLiteral reference, Relative, internal or absolute URL
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.

Cardinality1..1
Typestring
SummaryTrue
Comments

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, ref-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.author.identifier
ShortLogical reference, when literal reference is not known
Definition

An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity 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.

Cardinality0..1
TypeIdentifier
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • rim: .identifier
Composition.author.display
ShortText alternative for the resource
Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Cardinality0..1
Typestring
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.title
ShortHuman Readable name/title
Definition

Official human-readable label for the composition.

Cardinality1..1
Typestring
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.confidentiality
ShortAs defined by affinity domain
Definition

The code specifying the level of confidentiality of the Composition.

Cardinality0..0
Typecode
Binding

Codes specifying the level of confidentiality of the composition.

ConfidentialityClassification (required)

ModifierTrue
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .confidentialityCode
  • cda: .confidentialityCode
Composition.attester
ShortAttests to accuracy of composition
Definition

A participant who has attested to the accuracy of the composition/document.

Cardinality0..0
TypeBackboneElement
SummaryTrue
Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
  • cda: .authenticator/.legalAuthenticator
Composition.attester.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.attester.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.attester.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.attester.mode
Shortpersonal | professional | legal | official
Definition

The type of attestation the authenticator offers.

Cardinality1..*
Typecode
Binding

The way in which a person authenticated a composition.

CompositionAttestationMode (required)

SummaryTrue
Requirements

Indicates the level of authority of the attestation.

Comments

Use more than one code where a single attester has more than one mode (professional and legal are often paired).

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: unique(./modeCode)
  • cda: implied by .authenticator/.legalAuthenticator
Composition.attester.time
ShortWhen the composition was attested
Definition

When the composition was attested by the party.

Cardinality0..1
TypedateTime
SummaryTrue
Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./time[type="TS" and isNormalDatatype()]
  • cda: .authenticator.time
Composition.attester.party
ShortWho attested the composition
Definition

Who attested the composition in the specified way.

Cardinality0..1
TypeReference(CareConnect-Organization-1 | CareConnect-Patient-1 | CareConnect-Practitioner-1)
SummaryTrue
Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
  • cda: .authenticator.assignedEnttty
  • w5: who.witness
Composition.custodian
ShortOrganization which maintains the composition
Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.

Cardinality0..1
TypeReference(CareConnect-Organization-1)
Must SupportTrue
SummaryTrue
Requirements

Identifies where to go to find the current version, where to report issues, etc.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
  • cda: .custodian.assignedCustodian
Composition.custodian.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.custodian.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.custodian.reference
ShortLiteral reference, Relative, internal or absolute URL
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.

Cardinality1..1
Typestring
SummaryTrue
Comments

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, ref-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.custodian.identifier
ShortLogical reference, when literal reference is not known
Definition

An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity 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.

Cardinality0..1
TypeIdentifier
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • rim: .identifier
Composition.custodian.display
ShortText alternative for the resource
Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Cardinality0..1
Typestring
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.relatesTo
ShortRelationships to other compositions/documents
Definition

Relationships that this composition has with other compositions or documents that already exist.

Cardinality0..1
TypeBackboneElement
SummaryTrue
Comments

A document is a version specific composition.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outboundRelationship
  • cda: .relatedDocument
Composition.relatesTo.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.relatesTo.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.relatesTo.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.relatesTo.code
Shortreplaces | transforms | signs | appends
Definition

The type of relationship that this composition has with anther composition or document.

Cardinality1..1
Typecode
Binding

The type of relationship between documents.

DocumentRelationshipType (required)

SummaryTrue
Comments

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
replaces
Mappings
  • rim: n/a
  • rim: .outboundRelationship.typeCode
  • cda: .relatedDocument.typeCode
Composition.relatesTo.target[x]
ShortTarget of the relationship
Definition

The target composition/document of this relationship.

Cardinality1..1
TypeIdentifier | Reference(CareConnect-ITK-DM-Immunization-Composition-1)
SummaryTrue
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .target[classCode="DOC", moodCode="EVN"].id
  • cda: .relatedDocument.id
Composition.event
ShortThe clinical service(s) being documented
Definition

The clinical service, such as a colonoscopy or an appendectomy, being documented.

Cardinality0..0
TypeBackboneElement
SummaryTrue
Requirements

Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.

Comments

The event needs to be consistent with the type element, though can provide further information if desired.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
  • cda: .documentationOf.serviceEvent
Composition.event.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.event.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.event.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.event.code
ShortCode(s) that apply to the event being documented
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.

Cardinality0..*
TypeCodeableConcept
Binding

This list of codes represents the main clinical acts being documented.

v3 Code System ActCode (example)

SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .code
  • cda: .code
Composition.event.period
ShortThe period covered by the documentation
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.

Cardinality0..1
TypePeriod
SummaryTrue
Comments

This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval|Duration.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • per-1: If present, start SHALL have a lower value than end
    start.empty() or end.empty() or (start <= end)
Mappings
  • rim: n/a
  • v2: DR
  • rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
  • rim: .effectiveTime
  • cda: .effectiveTime
Composition.event.detail
ShortThe event(s) being documented
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.

Cardinality0..*
TypeReference(Resource)
SummaryTrue
Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode="SUBJ"].target
  • cda: n/a
Composition.section
ShortComposition is broken into sections
Definition

The root of the sections that make up the composition.

Cardinality1..*
TypeBackboneElement
Slicing

Unordered, Open, by code.coding.code(Value)

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • cmp-1: A section must 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()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section.title
ShortLabel for section (e.g. for ToC)
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.

Cardinality0..1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section.code
ShortClassification of section (recommended)
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Cardinality0..1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

Care Connect Composition Section Code (preferred)

Requirements

Provides computable standardized labels to topics within the document.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section.text
ShortText summary of the section, for human interpretation
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.

Cardinality0..1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section.mode
Shortworking | snapshot | changes
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.

Cardinality0..1
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)

ModifierTrue
SummaryTrue
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be mis-understood as a complete list.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
  • w5: class
Composition.section.orderedBy
ShortOrder of section entries
Definition

Specifies the order applied to the items in the section entries.

Cardinality0..1
TypeCodeableConcept
Binding

What order applies to the items in the entry.

List Order Codes (preferred)

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related 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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section.entry
ShortA reference to data that supports this section
Definition

A reference to the actual resource from which the narrative in the section is derived.

Cardinality0..*
TypeReference(Resource)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section.emptyReason
ShortWhy the section is empty
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Cardinality0..1
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

List Empty Reasons (preferred)

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]
  • cda: n/a
Composition.section.section
ShortNested Section
Definition

A nested sub-section within this section.

Cardinality0..*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1
Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:allergiesAndAdverseReactions
ShortComposition is broken into sections
Definition

The root of the sections that make up the composition.

Cardinality0..1
TypeBackboneElement
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • cmp-1: A section must 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()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:allergiesAndAdverseReactions.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:allergiesAndAdverseReactions.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:allergiesAndAdverseReactions.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:allergiesAndAdverseReactions.title
ShortAllergies and Adverse Reactions
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.

Cardinality1..1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:allergiesAndAdverseReactions.code
ShortClassification of section (recommended)
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Cardinality1..1
TypeCodeableConcept
Binding

A code from the SNOMED Clinical Terminology UK coding system which represents the type of section.

SNOMED_CT (required)

Requirements

Provides computable standardized labels to topics within the document.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:allergiesAndAdverseReactions.code.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:allergiesAndAdverseReactions.code.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:allergiesAndAdverseReactions.code.coding
ShortCode defined by a terminology system
Definition

A reference to a code defined by a terminology system.

Cardinality1..1
TypeCoding
SummaryTrue
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
  • rim: CV
  • orim: fhir:Coding rdfs:subClassOf dt:CDCoding
  • v2: C*E.1-8, C*E.10-22
  • rim: union(., ./translation)
  • orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Composition.section:allergiesAndAdverseReactions.code.coding.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:allergiesAndAdverseReactions.code.coding.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:allergiesAndAdverseReactions.code.coding.system
ShortIdentity of the terminology system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
http://snomed.info/sct
Mappings
  • rim: n/a
  • v2: C*E.3
  • rim: ./codeSystem
  • orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Composition.section:allergiesAndAdverseReactions.code.coding.version
ShortVersion of the system - if relevant
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Cardinality0..0
Typestring
SummaryTrue
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.7
  • rim: ./codeSystemVersion
  • orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Composition.section:allergiesAndAdverseReactions.code.coding.code
ShortSymbol in syntax defined by the system
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Cardinality1..1
Typecode
SummaryTrue
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
886921000000105
Mappings
  • rim: n/a
  • v2: C*E.1
  • rim: ./code
  • orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Composition.section:allergiesAndAdverseReactions.code.coding.display
ShortRepresentation defined by the system
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Cardinality1..1
Typestring
SummaryTrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Allergies and adverse reactions
Mappings
  • rim: n/a
  • v2: C*E.2 - but note this is not well followed
  • rim: CV.displayName
  • orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Composition.section:allergiesAndAdverseReactions.code.coding.userSelected
ShortIf this coding was chosen directly by the user
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Cardinality0..0
Typeboolean
SummaryTrue
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: Sometimes implied by being first
  • rim: CD.codingRationale
  • orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Composition.section:allergiesAndAdverseReactions.code.text
ShortPlain text representation of the concept
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Cardinality0..0
Typestring
SummaryTrue
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.9. But note many systems use C*E.2 for this
  • rim: ./originalText[mediaType/code="text/plain"]/data
  • orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Composition.section:allergiesAndAdverseReactions.text
ShortText summary of the section, for human interpretation
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.

Cardinality1..1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:allergiesAndAdverseReactions.mode
Shortworking | snapshot | changes
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.

Cardinality0..0
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)

ModifierTrue
SummaryTrue
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be mis-understood as a complete list.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
  • w5: class
Composition.section:allergiesAndAdverseReactions.orderedBy
ShortOrder of section entries
Definition

Specifies the order applied to the items in the section entries.

Cardinality0..0
TypeCodeableConcept
Binding

What order applies to the items in the entry.

List Order Codes (preferred)

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related 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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:allergiesAndAdverseReactions.entry
ShortA reference to data that supports this section
Definition

A reference to the actual resource from which the narrative in the section is derived.

Cardinality0..*
TypeReference(CareConnect-ITK-Allergy-List-1 | ITK-Attachment-Binary-1)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:allergiesAndAdverseReactions.emptyReason
ShortWhy the section is empty
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Cardinality0..0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

List Empty Reasons (preferred)

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]
  • cda: n/a
Composition.section:allergiesAndAdverseReactions.section
ShortNested Section
Definition

A nested sub-section within this section.

Cardinality0..*
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1
Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:attendanceDetails
ShortInformation relating to the patients attendance.
Definition

Information relating to the patients attendance.

Cardinality0..1
TypeBackboneElement
Must SupportTrue
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • cmp-1: A section must 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()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:attendanceDetails.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:attendanceDetails.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:attendanceDetails.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:attendanceDetails.title
ShortLabel for section (e.g. for ToC)
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.

Cardinality1..1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Attendance Details
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:attendanceDetails.code
ShortClassification of section (recommended)
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Cardinality1..1
TypeCodeableConcept
Binding

A code from the SNOMED Clinical Terminology UK coding system which represents the type of section.

SNOMED_CT (required)

Requirements

Provides computable standardized labels to topics within the document.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:attendanceDetails.code.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:attendanceDetails.code.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:attendanceDetails.code.coding
ShortCode defined by a terminology system
Definition

A reference to a code defined by a terminology system.

Cardinality1..1
TypeCoding
SummaryTrue
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
  • rim: CV
  • orim: fhir:Coding rdfs:subClassOf dt:CDCoding
  • v2: C*E.1-8, C*E.10-22
  • rim: union(., ./translation)
  • orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Composition.section:attendanceDetails.code.coding.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:attendanceDetails.code.coding.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:attendanceDetails.code.coding.system
ShortIdentity of the terminology system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
http://snomed.info/sct
Mappings
  • rim: n/a
  • v2: C*E.3
  • rim: ./codeSystem
  • orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Composition.section:attendanceDetails.code.coding.version
ShortVersion of the system - if relevant
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Cardinality0..0
Typestring
SummaryTrue
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.7
  • rim: ./codeSystemVersion
  • orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Composition.section:attendanceDetails.code.coding.code
ShortSymbol in syntax defined by the system
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Cardinality1..1
Typecode
SummaryTrue
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
1077881000000105
Mappings
  • rim: n/a
  • v2: C*E.1
  • rim: ./code
  • orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Composition.section:attendanceDetails.code.coding.display
ShortRepresentation defined by the system
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Cardinality1..1
Typestring
SummaryTrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Attendance details
Mappings
  • rim: n/a
  • v2: C*E.2 - but note this is not well followed
  • rim: CV.displayName
  • orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Composition.section:attendanceDetails.code.coding.userSelected
ShortIf this coding was chosen directly by the user
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Cardinality0..0
Typeboolean
SummaryTrue
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: Sometimes implied by being first
  • rim: CD.codingRationale
  • orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Composition.section:attendanceDetails.code.text
ShortPlain text representation of the concept
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Cardinality0..0
Typestring
SummaryTrue
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.9. But note many systems use C*E.2 for this
  • rim: ./originalText[mediaType/code="text/plain"]/data
  • orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Composition.section:attendanceDetails.text
ShortText summary of the section, for human interpretation
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.

Cardinality1..1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:attendanceDetails.mode
Shortworking | snapshot | changes
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.

Cardinality0..0
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)

ModifierTrue
SummaryTrue
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be mis-understood as a complete list.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
  • w5: class
Composition.section:attendanceDetails.orderedBy
ShortOrder of section entries
Definition

Specifies the order applied to the items in the section entries.

Cardinality0..0
TypeCodeableConcept
Binding

What order applies to the items in the entry.

List Order Codes (preferred)

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related 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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:attendanceDetails.entry
ShortA reference to data that supports this section
Definition

A reference to the actual resource from which the narrative in the section is derived.

Cardinality1..1
TypeReference(CareConnect-ITK-Encounter-1)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:attendanceDetails.entry.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:attendanceDetails.entry.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:attendanceDetails.entry.reference
ShortLiteral reference, Relative, internal or absolute URL
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.

Cardinality1..1
Typestring
SummaryTrue
Comments

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, ref-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:attendanceDetails.entry.identifier
ShortLogical reference, when literal reference is not known
Definition

An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity 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.

Cardinality0..1
TypeIdentifier
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • rim: .identifier
Composition.section:attendanceDetails.entry.display
ShortText alternative for the resource
Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Cardinality0..1
Typestring
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:attendanceDetails.emptyReason
ShortWhy the section is empty
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Cardinality0..0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

List Empty Reasons (preferred)

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]
  • cda: n/a
Composition.section:attendanceDetails.section
ShortNested Section
Definition

A nested sub-section within this section.

Cardinality0..0
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1
Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:consent
ShortInformation on patients consent for treatment and information sharing guidance.
Definition

Information on patients consent for treatment and information sharing guidance.

Cardinality0..1
TypeBackboneElement
Must SupportTrue
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • cmp-1: A section must 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()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:consent.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:consent.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:consent.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:consent.title
ShortLabel for section (e.g. for ToC)
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.

Cardinality1..1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Consent
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:consent.code
ShortClassification of section (recommended)
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Cardinality1..1
TypeCodeableConcept
Binding

A code from the SNOMED Clinical Terminology UK coding system which represents the type of section.

SNOMED_CT (required)

Requirements

Provides computable standardized labels to topics within the document.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:consent.code.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:consent.code.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:consent.code.coding
ShortCode defined by a terminology system
Definition

A reference to a code defined by a terminology system.

Cardinality1..1
TypeCoding
SummaryTrue
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
  • rim: CV
  • orim: fhir:Coding rdfs:subClassOf dt:CDCoding
  • v2: C*E.1-8, C*E.10-22
  • rim: union(., ./translation)
  • orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Composition.section:consent.code.coding.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:consent.code.coding.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:consent.code.coding.system
ShortIdentity of the terminology system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
http://snomed.info/sct
Mappings
  • rim: n/a
  • v2: C*E.3
  • rim: ./codeSystem
  • orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Composition.section:consent.code.coding.version
ShortVersion of the system - if relevant
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Cardinality0..0
Typestring
SummaryTrue
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.7
  • rim: ./codeSystemVersion
  • orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Composition.section:consent.code.coding.code
ShortSymbol in syntax defined by the system
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Cardinality1..1
Typecode
SummaryTrue
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
61861000000100
Mappings
  • rim: n/a
  • v2: C*E.1
  • rim: ./code
  • orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Composition.section:consent.code.coding.display
ShortRepresentation defined by the system
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Cardinality1..1
Typestring
SummaryTrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Consent
Mappings
  • rim: n/a
  • v2: C*E.2 - but note this is not well followed
  • rim: CV.displayName
  • orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Composition.section:consent.code.coding.userSelected
ShortIf this coding was chosen directly by the user
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Cardinality0..0
Typeboolean
SummaryTrue
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: Sometimes implied by being first
  • rim: CD.codingRationale
  • orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Composition.section:consent.code.text
ShortPlain text representation of the concept
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Cardinality0..0
Typestring
SummaryTrue
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.9. But note many systems use C*E.2 for this
  • rim: ./originalText[mediaType/code="text/plain"]/data
  • orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Composition.section:consent.text
ShortText summary of the section, for human interpretation
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.

Cardinality1..1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:consent.mode
Shortworking | snapshot | changes
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.

Cardinality0..0
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)

ModifierTrue
SummaryTrue
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be mis-understood as a complete list.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
  • w5: class
Composition.section:consent.orderedBy
ShortOrder of section entries
Definition

Specifies the order applied to the items in the section entries.

Cardinality0..0
TypeCodeableConcept
Binding

What order applies to the items in the entry.

List Order Codes (preferred)

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related 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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:consent.entry
ShortA reference to data that supports this section
Definition

A reference to the actual resource from which the narrative in the section is derived.

Cardinality0..0
TypeReference(Resource)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:consent.emptyReason
ShortWhy the section is empty
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Cardinality0..0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

List Empty Reasons (preferred)

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]
  • cda: n/a
Composition.section:consent.section
ShortNested Section
Definition

A nested sub-section within this section.

Cardinality0..0
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1
Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:distributionList
ShortComposition is broken into sections
Definition

The root of the sections that make up the composition.

Cardinality0..1
TypeBackboneElement
Must SupportTrue
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • cmp-1: A section must 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()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:distributionList.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:distributionList.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:distributionList.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:distributionList.title
ShortLabel for section (e.g. for ToC)
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.

Cardinality1..1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Distribution list
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:distributionList.code
ShortClassification of section (recommended)
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Cardinality1..1
TypeCodeableConcept
Binding

Classification of a section of a composition/document.

Document Section Codes (example)

Requirements

Provides computable standardized labels to topics within the document.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:distributionList.code.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:distributionList.code.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:distributionList.code.coding
ShortCode defined by a terminology system
Definition

A reference to a code defined by a terminology system.

Cardinality1..1
TypeCoding
SummaryTrue
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
  • rim: CV
  • orim: fhir:Coding rdfs:subClassOf dt:CDCoding
  • v2: C*E.1-8, C*E.10-22
  • rim: union(., ./translation)
  • orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Composition.section:distributionList.code.coding.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:distributionList.code.coding.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:distributionList.code.coding.system
ShortIdentity of the terminology system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
http://snomed.info/sct
Mappings
  • rim: n/a
  • v2: C*E.3
  • rim: ./codeSystem
  • orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Composition.section:distributionList.code.coding.version
ShortVersion of the system - if relevant
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Cardinality0..0
Typestring
SummaryTrue
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.7
  • rim: ./codeSystemVersion
  • orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Composition.section:distributionList.code.coding.code
ShortSymbol in syntax defined by the system
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Cardinality1..1
Typecode
SummaryTrue
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
887261000000109
Mappings
  • rim: n/a
  • v2: C*E.1
  • rim: ./code
  • orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Composition.section:distributionList.code.coding.display
ShortRepresentation defined by the system
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Cardinality1..1
Typestring
SummaryTrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Distribution list
Mappings
  • rim: n/a
  • v2: C*E.2 - but note this is not well followed
  • rim: CV.displayName
  • orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Composition.section:distributionList.code.coding.userSelected
ShortIf this coding was chosen directly by the user
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Cardinality0..0
Typeboolean
SummaryTrue
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: Sometimes implied by being first
  • rim: CD.codingRationale
  • orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Composition.section:distributionList.code.text
ShortPlain text representation of the concept
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Cardinality0..0
Typestring
SummaryTrue
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.9. But note many systems use C*E.2 for this
  • rim: ./originalText[mediaType/code="text/plain"]/data
  • orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Composition.section:distributionList.text
ShortText summary of the section, for human interpretation
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.

Cardinality1..1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:distributionList.mode
Shortworking | snapshot | changes
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.

Cardinality0..0
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)

ModifierTrue
SummaryTrue
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be mis-understood as a complete list.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
  • w5: class
Composition.section:distributionList.orderedBy
ShortOrder of section entries
Definition

Specifies the order applied to the items in the section entries.

Cardinality0..0
TypeCodeableConcept
Binding

What order applies to the items in the entry.

List Order Codes (preferred)

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related 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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:distributionList.entry
ShortA reference to data that supports this section
Definition

A reference to the actual resource from which the narrative in the section is derived.

Cardinality0..*
TypeReference(CareConnect-Organization-1 | CareConnect-Patient-1 | CareConnect-Practitioner-1 | CareConnect-PractitionerRole-1 | CareConnect-RelatedPerson-1 | ITK-Attachment-Binary-1 | ITK-RelatedPerson-1)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:distributionList.entry.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:distributionList.entry.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:distributionList.entry.reference
ShortLiteral reference, Relative, internal or absolute URL
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.

Cardinality1..1
Typestring
SummaryTrue
Comments

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, ref-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:distributionList.entry.identifier
ShortLogical reference, when literal reference is not known
Definition

An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity 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.

Cardinality0..1
TypeIdentifier
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • rim: .identifier
Composition.section:distributionList.entry.display
ShortText alternative for the resource
Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Cardinality0..1
Typestring
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:distributionList.emptyReason
ShortWhy the section is empty
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Cardinality0..0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

List Empty Reasons (preferred)

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]
  • cda: n/a
Composition.section:distributionList.section
ShortNested Section
Definition

A nested sub-section within this section.

Cardinality0..0
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1
Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:gpPractice
ShortInformation realting to the patients registered GP Practice.
Definition

Information realting to the patients registered GP Practice.

Cardinality1..1
TypeBackboneElement
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • cmp-1: A section must 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()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:gpPractice.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:gpPractice.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:gpPractice.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:gpPractice.title
ShortLabel for section (e.g. for ToC)
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.

Cardinality1..1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
GP Practice
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:gpPractice.code
ShortClassification of section (recommended)
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Cardinality1..1
TypeCodeableConcept
Binding

A code from the SNOMED Clinical Terminology UK coding system which represents the type of section.

SNOMED_CT (required)

Requirements

Provides computable standardized labels to topics within the document.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:gpPractice.code.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:gpPractice.code.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:gpPractice.code.coding
ShortCode defined by a terminology system
Definition

A reference to a code defined by a terminology system.

Cardinality1..1
TypeCoding
SummaryTrue
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
  • rim: CV
  • orim: fhir:Coding rdfs:subClassOf dt:CDCoding
  • v2: C*E.1-8, C*E.10-22
  • rim: union(., ./translation)
  • orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Composition.section:gpPractice.code.coding.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:gpPractice.code.coding.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:gpPractice.code.coding.system
ShortIdentity of the terminology system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
http://snomed.info/sct
Mappings
  • rim: n/a
  • v2: C*E.3
  • rim: ./codeSystem
  • orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Composition.section:gpPractice.code.coding.version
ShortVersion of the system - if relevant
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Cardinality0..0
Typestring
SummaryTrue
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.7
  • rim: ./codeSystemVersion
  • orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Composition.section:gpPractice.code.coding.code
ShortSymbol in syntax defined by the system
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Cardinality1..1
Typecode
SummaryTrue
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
886711000000101
Mappings
  • rim: n/a
  • v2: C*E.1
  • rim: ./code
  • orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Composition.section:gpPractice.code.coding.display
ShortRepresentation defined by the system
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Cardinality1..1
Typestring
SummaryTrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
GP practice
Mappings
  • rim: n/a
  • v2: C*E.2 - but note this is not well followed
  • rim: CV.displayName
  • orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Composition.section:gpPractice.code.coding.userSelected
ShortIf this coding was chosen directly by the user
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Cardinality0..0
Typeboolean
SummaryTrue
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: Sometimes implied by being first
  • rim: CD.codingRationale
  • orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Composition.section:gpPractice.code.text
ShortPlain text representation of the concept
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Cardinality0..0
Typestring
SummaryTrue
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.9. But note many systems use C*E.2 for this
  • rim: ./originalText[mediaType/code="text/plain"]/data
  • orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Composition.section:gpPractice.text
ShortText summary of the section, for human interpretation
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.

Cardinality1..1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:gpPractice.mode
Shortworking | snapshot | changes
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.

Cardinality0..0
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)

ModifierTrue
SummaryTrue
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be mis-understood as a complete list.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
  • w5: class
Composition.section:gpPractice.orderedBy
ShortOrder of section entries
Definition

Specifies the order applied to the items in the section entries.

Cardinality0..0
TypeCodeableConcept
Binding

What order applies to the items in the entry.

List Order Codes (preferred)

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related 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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:gpPractice.entry
ShortA reference to data that supports this section
Definition

A reference to the actual resource from which the narrative in the section is derived.

Cardinality1..1
TypeReference(CareConnect-Organization-1)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:gpPractice.entry.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:gpPractice.entry.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:gpPractice.entry.reference
ShortLiteral reference, Relative, internal or absolute URL
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.

Cardinality1..1
Typestring
SummaryTrue
Comments

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, ref-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:gpPractice.entry.identifier
ShortLogical reference, when literal reference is not known
Definition

An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity 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.

Cardinality0..1
TypeIdentifier
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • rim: .identifier
Composition.section:gpPractice.entry.display
ShortText alternative for the resource
Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Cardinality0..1
Typestring
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:gpPractice.emptyReason
ShortWhy the section is empty
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Cardinality0..0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

List Empty Reasons (preferred)

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]
  • cda: n/a
Composition.section:gpPractice.section
ShortNested Section
Definition

A nested sub-section within this section.

Cardinality0..0
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1
Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:history
ShortRelevant past medical, surgical and mental health history.
Definition

History pertinent to the vaccination e.g. contraindications, pregnancy, immunosupression etc.

Cardinality0..1
TypeBackboneElement
Must SupportTrue
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • cmp-1: A section must 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()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:history.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:history.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:history.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:history.title
ShortLabel for section (e.g. for ToC)
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.

Cardinality1..1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
History
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:history.code
ShortClassification of section (recommended)
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Cardinality1..1
TypeCodeableConcept
Binding

A code from the SNOMED Clinical Terminology UK coding system which represents the type of section.

SNOMED_CT (required)

Requirements

Provides computable standardized labels to topics within the document.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:history.code.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:history.code.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:history.code.coding
ShortCode defined by a terminology system
Definition

A reference to a code defined by a terminology system.

Cardinality1..1
TypeCoding
SummaryTrue
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
  • rim: CV
  • orim: fhir:Coding rdfs:subClassOf dt:CDCoding
  • v2: C*E.1-8, C*E.10-22
  • rim: union(., ./translation)
  • orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Composition.section:history.code.coding.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:history.code.coding.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:history.code.coding.system
ShortIdentity of the terminology system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
http://snomed.info/sct
Mappings
  • rim: n/a
  • v2: C*E.3
  • rim: ./codeSystem
  • orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Composition.section:history.code.coding.version
ShortVersion of the system - if relevant
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Cardinality0..0
Typestring
SummaryTrue
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.7
  • rim: ./codeSystemVersion
  • orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Composition.section:history.code.coding.code
ShortSymbol in syntax defined by the system
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Cardinality1..1
Typecode
SummaryTrue
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
717121000000105
Mappings
  • rim: n/a
  • v2: C*E.1
  • rim: ./code
  • orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Composition.section:history.code.coding.display
ShortRepresentation defined by the system
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Cardinality1..1
Typestring
SummaryTrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
History
Mappings
  • rim: n/a
  • v2: C*E.2 - but note this is not well followed
  • rim: CV.displayName
  • orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Composition.section:history.code.coding.userSelected
ShortIf this coding was chosen directly by the user
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Cardinality0..0
Typeboolean
SummaryTrue
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: Sometimes implied by being first
  • rim: CD.codingRationale
  • orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Composition.section:history.code.text
ShortPlain text representation of the concept
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Cardinality0..0
Typestring
SummaryTrue
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.9. But note many systems use C*E.2 for this
  • rim: ./originalText[mediaType/code="text/plain"]/data
  • orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Composition.section:history.text
ShortText summary of the section, for human interpretation
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.

Cardinality1..1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:history.mode
Shortworking | snapshot | changes
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.

Cardinality0..0
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)

ModifierTrue
SummaryTrue
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be mis-understood as a complete list.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
  • w5: class
Composition.section:history.orderedBy
ShortOrder of section entries
Definition

Specifies the order applied to the items in the section entries.

Cardinality0..0
TypeCodeableConcept
Binding

What order applies to the items in the entry.

List Order Codes (preferred)

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related 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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:history.entry
ShortA reference to data that supports this section
Definition

A reference to the actual resource from which the narrative in the section is derived.

Cardinality0..0
TypeReference(Resource)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:history.emptyReason
ShortWhy the section is empty
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Cardinality0..0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

List Empty Reasons (preferred)

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]
  • cda: n/a
Composition.section:history.section
ShortNested Section
Definition

A nested sub-section within this section.

Cardinality0..0
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1
Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:informationAndAdviceGiven
ShortInformation or advice given.
Definition

The oral or written information or advice given to the patient, carer, other authorised representative, care professional or other third party.

Cardinality0..1
TypeBackboneElement
Must SupportTrue
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • cmp-1: A section must 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()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:informationAndAdviceGiven.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:informationAndAdviceGiven.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:informationAndAdviceGiven.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:informationAndAdviceGiven.title
ShortLabel for section (e.g. for ToC)
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.

Cardinality1..1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Information and Advice given
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:informationAndAdviceGiven.code
ShortClassification of section (recommended)
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Cardinality1..1
TypeCodeableConcept
Binding

A code from the SNOMED Clinical Terminology UK coding system which represents the type of section.

SNOMED_CT (required)

Requirements

Provides computable standardized labels to topics within the document.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:informationAndAdviceGiven.code.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:informationAndAdviceGiven.code.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:informationAndAdviceGiven.code.coding
ShortCode defined by a terminology system
Definition

A reference to a code defined by a terminology system.

Cardinality1..1
TypeCoding
SummaryTrue
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
  • rim: CV
  • orim: fhir:Coding rdfs:subClassOf dt:CDCoding
  • v2: C*E.1-8, C*E.10-22
  • rim: union(., ./translation)
  • orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Composition.section:informationAndAdviceGiven.code.coding.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:informationAndAdviceGiven.code.coding.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:informationAndAdviceGiven.code.coding.system
ShortIdentity of the terminology system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
http://snomed.info/sct
Mappings
  • rim: n/a
  • v2: C*E.3
  • rim: ./codeSystem
  • orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Composition.section:informationAndAdviceGiven.code.coding.version
ShortVersion of the system - if relevant
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Cardinality0..0
Typestring
SummaryTrue
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.7
  • rim: ./codeSystemVersion
  • orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Composition.section:informationAndAdviceGiven.code.coding.code
ShortSymbol in syntax defined by the system
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Cardinality1..1
Typecode
SummaryTrue
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
1052951000000105
Mappings
  • rim: n/a
  • v2: C*E.1
  • rim: ./code
  • orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Composition.section:informationAndAdviceGiven.code.coding.display
ShortRepresentation defined by the system
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Cardinality1..1
Typestring
SummaryTrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Information and advice given
Mappings
  • rim: n/a
  • v2: C*E.2 - but note this is not well followed
  • rim: CV.displayName
  • orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Composition.section:informationAndAdviceGiven.code.coding.userSelected
ShortIf this coding was chosen directly by the user
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Cardinality0..0
Typeboolean
SummaryTrue
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: Sometimes implied by being first
  • rim: CD.codingRationale
  • orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Composition.section:informationAndAdviceGiven.code.text
ShortPlain text representation of the concept
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Cardinality0..0
Typestring
SummaryTrue
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.9. But note many systems use C*E.2 for this
  • rim: ./originalText[mediaType/code="text/plain"]/data
  • orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Composition.section:informationAndAdviceGiven.text
ShortText summary of the section, for human interpretation
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.

Cardinality1..1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:informationAndAdviceGiven.mode
Shortworking | snapshot | changes
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.

Cardinality0..0
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)

ModifierTrue
SummaryTrue
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be mis-understood as a complete list.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
  • w5: class
Composition.section:informationAndAdviceGiven.orderedBy
ShortOrder of section entries
Definition

Specifies the order applied to the items in the section entries.

Cardinality0..0
TypeCodeableConcept
Binding

What order applies to the items in the entry.

List Order Codes (preferred)

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related 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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:informationAndAdviceGiven.entry
ShortA reference to data that supports this section
Definition

A reference to the actual resource from which the narrative in the section is derived.

Cardinality0..0
TypeReference(Resource)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:informationAndAdviceGiven.emptyReason
ShortWhy the section is empty
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Cardinality0..0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

List Empty Reasons (preferred)

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]
  • cda: n/a
Composition.section:informationAndAdviceGiven.section
ShortNested Section
Definition

A nested sub-section within this section.

Cardinality0..0
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1
Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:medicationsAndMedicalDevices
ShortComposition is broken into sections
Definition

The root of the sections that make up the composition.

Cardinality1..1
TypeBackboneElement
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • cmp-1: A section must 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()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:medicationsAndMedicalDevices.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:medicationsAndMedicalDevices.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:medicationsAndMedicalDevices.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:medicationsAndMedicalDevices.title
ShortLabel for section (e.g. for ToC)
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.

Cardinality1..1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Medications and medical devices
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:medicationsAndMedicalDevices.code
ShortClassification of section (recommended)
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Cardinality1..1
TypeCodeableConcept
Binding

A code from the SNOMED Clinical Terminology UK coding system which represents the type of section.

SNOMED_CT (required)

Requirements

Provides computable standardized labels to topics within the document.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:medicationsAndMedicalDevices.code.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:medicationsAndMedicalDevices.code.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:medicationsAndMedicalDevices.code.coding
ShortCode defined by a terminology system
Definition

A reference to a code defined by a terminology system.

Cardinality1..1
TypeCoding
SummaryTrue
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
  • rim: CV
  • orim: fhir:Coding rdfs:subClassOf dt:CDCoding
  • v2: C*E.1-8, C*E.10-22
  • rim: union(., ./translation)
  • orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Composition.section:medicationsAndMedicalDevices.code.coding.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:medicationsAndMedicalDevices.code.coding.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:medicationsAndMedicalDevices.code.coding.system
ShortIdentity of the terminology system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
http://snomed.info/sct
Mappings
  • rim: n/a
  • v2: C*E.3
  • rim: ./codeSystem
  • orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Composition.section:medicationsAndMedicalDevices.code.coding.version
ShortVersion of the system - if relevant
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Cardinality0..0
Typestring
SummaryTrue
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.7
  • rim: ./codeSystemVersion
  • orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Composition.section:medicationsAndMedicalDevices.code.coding.code
ShortSymbol in syntax defined by the system
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Cardinality1..1
Typecode
SummaryTrue
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
933361000000108
Mappings
  • rim: n/a
  • v2: C*E.1
  • rim: ./code
  • orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Composition.section:medicationsAndMedicalDevices.code.coding.display
ShortRepresentation defined by the system
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Cardinality1..1
Typestring
SummaryTrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Medications and medical devices
Mappings
  • rim: n/a
  • v2: C*E.2 - but note this is not well followed
  • rim: CV.displayName
  • orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Composition.section:medicationsAndMedicalDevices.code.coding.userSelected
ShortIf this coding was chosen directly by the user
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Cardinality0..0
Typeboolean
SummaryTrue
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: Sometimes implied by being first
  • rim: CD.codingRationale
  • orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Composition.section:medicationsAndMedicalDevices.code.text
ShortPlain text representation of the concept
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Cardinality0..0
Typestring
SummaryTrue
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.9. But note many systems use C*E.2 for this
  • rim: ./originalText[mediaType/code="text/plain"]/data
  • orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Composition.section:medicationsAndMedicalDevices.text
ShortText summary of the section, for human interpretation
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.

Cardinality1..1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:medicationsAndMedicalDevices.mode
Shortworking | snapshot | changes
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.

Cardinality0..0
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)

ModifierTrue
SummaryTrue
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be mis-understood as a complete list.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
  • w5: class
Composition.section:medicationsAndMedicalDevices.orderedBy
ShortOrder of section entries
Definition

Specifies the order applied to the items in the section entries.

Cardinality0..0
TypeCodeableConcept
Binding

What order applies to the items in the entry.

List Order Codes (preferred)

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related 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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:medicationsAndMedicalDevices.entry
ShortA reference to data that supports this section
Definition

A reference to the actual resource from which the narrative in the section is derived.

Cardinality1..1
TypeReference(CareConnect-ITK-MedicationDispense-List-1)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:medicationsAndMedicalDevices.entry.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:medicationsAndMedicalDevices.entry.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:medicationsAndMedicalDevices.entry.reference
ShortLiteral reference, Relative, internal or absolute URL
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.

Cardinality1..1
Typestring
SummaryTrue
Comments

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, ref-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:medicationsAndMedicalDevices.entry.identifier
ShortLogical reference, when literal reference is not known
Definition

An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity 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.

Cardinality0..1
TypeIdentifier
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • rim: .identifier
Composition.section:medicationsAndMedicalDevices.entry.display
ShortText alternative for the resource
Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Cardinality0..1
Typestring
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:medicationsAndMedicalDevices.emptyReason
ShortWhy the section is empty
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Cardinality0..0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

List Empty Reasons (preferred)

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]
  • cda: n/a
Composition.section:medicationsAndMedicalDevices.section
ShortNested Section
Definition

A nested sub-section within this section.

Cardinality0..0
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1
Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:patientDemographics
ShortPatient demographic information including the patient's next of kin and carer information.
Definition

Patient demographic information including the patient's next of kin and carer information.

Cardinality1..1
TypeBackboneElement
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • cmp-1: A section must 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()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:patientDemographics.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:patientDemographics.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:patientDemographics.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:patientDemographics.title
ShortLabel for section (e.g. for ToC)
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.

Cardinality1..1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Patient Demographics
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:patientDemographics.code
ShortClassification of section (recommended)
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Cardinality1..1
TypeCodeableConcept
Binding

A code from the SNOMED Clinical Terminology UK coding system which represents the type of section.

SNOMED_CT (required)

Requirements

Provides computable standardized labels to topics within the document.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:patientDemographics.code.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:patientDemographics.code.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:patientDemographics.code.coding
ShortCode defined by a terminology system
Definition

A reference to a code defined by a terminology system.

Cardinality1..1
TypeCoding
SummaryTrue
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
  • rim: CV
  • orim: fhir:Coding rdfs:subClassOf dt:CDCoding
  • v2: C*E.1-8, C*E.10-22
  • rim: union(., ./translation)
  • orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Composition.section:patientDemographics.code.coding.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:patientDemographics.code.coding.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:patientDemographics.code.coding.system
ShortIdentity of the terminology system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
http://snomed.info/sct
Mappings
  • rim: n/a
  • v2: C*E.3
  • rim: ./codeSystem
  • orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Composition.section:patientDemographics.code.coding.version
ShortVersion of the system - if relevant
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Cardinality0..0
Typestring
SummaryTrue
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.7
  • rim: ./codeSystemVersion
  • orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Composition.section:patientDemographics.code.coding.code
ShortSymbol in syntax defined by the system
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Cardinality1..1
Typecode
SummaryTrue
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
886731000000109
Mappings
  • rim: n/a
  • v2: C*E.1
  • rim: ./code
  • orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Composition.section:patientDemographics.code.coding.display
ShortRepresentation defined by the system
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Cardinality1..1
Typestring
SummaryTrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Patient demographics
Mappings
  • rim: n/a
  • v2: C*E.2 - but note this is not well followed
  • rim: CV.displayName
  • orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Composition.section:patientDemographics.code.coding.userSelected
ShortIf this coding was chosen directly by the user
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Cardinality0..0
Typeboolean
SummaryTrue
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: Sometimes implied by being first
  • rim: CD.codingRationale
  • orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Composition.section:patientDemographics.code.text
ShortPlain text representation of the concept
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Cardinality0..0
Typestring
SummaryTrue
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.9. But note many systems use C*E.2 for this
  • rim: ./originalText[mediaType/code="text/plain"]/data
  • orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Composition.section:patientDemographics.text
ShortText summary of the section, for human interpretation
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.

Cardinality1..1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:patientDemographics.mode
Shortworking | snapshot | changes
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.

Cardinality0..0
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)

ModifierTrue
SummaryTrue
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be mis-understood as a complete list.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
  • w5: class
Composition.section:patientDemographics.orderedBy
ShortOrder of section entries
Definition

Specifies the order applied to the items in the section entries.

Cardinality0..0
TypeCodeableConcept
Binding

What order applies to the items in the entry.

List Order Codes (preferred)

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related 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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:patientDemographics.entry
ShortA reference to data that supports this section
Definition

A reference to the actual resource from which the narrative in the section is derived.

Cardinality1..1
TypeReference(CareConnect-Patient-1)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:patientDemographics.entry.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:patientDemographics.entry.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:patientDemographics.entry.reference
ShortLiteral reference, Relative, internal or absolute URL
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.

Cardinality1..1
Typestring
SummaryTrue
Comments

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, ref-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:patientDemographics.entry.identifier
ShortLogical reference, when literal reference is not known
Definition

An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity 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.

Cardinality0..1
TypeIdentifier
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • rim: .identifier
Composition.section:patientDemographics.entry.display
ShortText alternative for the resource
Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Cardinality0..1
Typestring
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:patientDemographics.emptyReason
ShortWhy the section is empty
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Cardinality0..0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

List Empty Reasons (preferred)

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]
  • cda: n/a
Composition.section:patientDemographics.section
ShortNested Section
Definition

A nested sub-section within this section.

Cardinality0..0
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1
Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:planAndRequestedActions
ShortComposition is broken into sections
Definition

The root of the sections that make up the composition.

Cardinality0..1
TypeBackboneElement
Must SupportTrue
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • cmp-1: A section must 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()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:planAndRequestedActions.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:planAndRequestedActions.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:planAndRequestedActions.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:planAndRequestedActions.title
ShortLabel for section (e.g. for ToC)
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.

Cardinality1..1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Plan and requested actions
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:planAndRequestedActions.code
ShortClassification of section (recommended)
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Cardinality1..1
TypeCodeableConcept
Binding

A code from the SNOMED Clinical Terminology UK coding system which represents the type of section.

SNOMED_CT (required)

Requirements

Provides computable standardized labels to topics within the document.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:planAndRequestedActions.code.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:planAndRequestedActions.code.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:planAndRequestedActions.code.coding
ShortCode defined by a terminology system
Definition

A reference to a code defined by a terminology system.

Cardinality1..1
TypeCoding
SummaryTrue
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
  • rim: CV
  • orim: fhir:Coding rdfs:subClassOf dt:CDCoding
  • v2: C*E.1-8, C*E.10-22
  • rim: union(., ./translation)
  • orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Composition.section:planAndRequestedActions.code.coding.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:planAndRequestedActions.code.coding.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:planAndRequestedActions.code.coding.system
ShortIdentity of the terminology system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
http://snomed.info/sct
Mappings
  • rim: n/a
  • v2: C*E.3
  • rim: ./codeSystem
  • orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Composition.section:planAndRequestedActions.code.coding.version
ShortVersion of the system - if relevant
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Cardinality0..0
Typestring
SummaryTrue
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.7
  • rim: ./codeSystemVersion
  • orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Composition.section:planAndRequestedActions.code.coding.code
ShortSymbol in syntax defined by the system
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Cardinality1..1
Typecode
SummaryTrue
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
887201000000105
Mappings
  • rim: n/a
  • v2: C*E.1
  • rim: ./code
  • orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Composition.section:planAndRequestedActions.code.coding.display
ShortRepresentation defined by the system
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Cardinality1..1
Typestring
SummaryTrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Plan and requested actions
Mappings
  • rim: n/a
  • v2: C*E.2 - but note this is not well followed
  • rim: CV.displayName
  • orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Composition.section:planAndRequestedActions.code.coding.userSelected
ShortIf this coding was chosen directly by the user
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Cardinality0..0
Typeboolean
SummaryTrue
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: Sometimes implied by being first
  • rim: CD.codingRationale
  • orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Composition.section:planAndRequestedActions.code.text
ShortPlain text representation of the concept
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Cardinality0..0
Typestring
SummaryTrue
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.9. But note many systems use C*E.2 for this
  • rim: ./originalText[mediaType/code="text/plain"]/data
  • orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Composition.section:planAndRequestedActions.text
ShortText summary of the section, for human interpretation
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.

Cardinality1..1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:planAndRequestedActions.mode
Shortworking | snapshot | changes
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.

Cardinality0..0
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)

ModifierTrue
SummaryTrue
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be mis-understood as a complete list.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
  • w5: class
Composition.section:planAndRequestedActions.orderedBy
ShortOrder of section entries
Definition

Specifies the order applied to the items in the section entries.

Cardinality0..0
TypeCodeableConcept
Binding

What order applies to the items in the entry.

List Order Codes (preferred)

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related 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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:planAndRequestedActions.entry
ShortA reference to data that supports this section
Definition

A reference to the actual resource from which the narrative in the section is derived.

Cardinality0..0
TypeReference(Resource)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:planAndRequestedActions.emptyReason
ShortWhy the section is empty
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Cardinality0..0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

List Empty Reasons (preferred)

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]
  • cda: n/a
Composition.section:planAndRequestedActions.section
ShortNested Section
Definition

A nested sub-section within this section.

Cardinality0..0
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1
Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section
Composition.section:referralDetails
ShortDetails of the individual or team who referred the patient.
Definition

Details of the individual or team who referred the patient.

Cardinality0..1
TypeBackboneElement
Must SupportTrue
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • cmp-1: A section must 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()
Mappings
  • rim: n/a
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.structuredBody.component.section
Composition.section:referralDetails.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:referralDetails.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:referralDetails.modifierExtension
ShortExtensions that cannot be ignored
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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:referralDetails.title
ShortReferral Details
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.

Cardinality1..1
Typestring
Aliasheader, label, caption
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: ./title
  • cda: .title
Composition.section:referralDetails.code
ShortClassification of section (recommended)
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Cardinality1..1
TypeCodeableConcept
Binding

A code from the SNOMED Clinical Terminology UK coding system which represents the type of section.

SNOMED_CT (required)

Requirements

Provides computable standardized labels to topics within the document.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: ./code
  • cda: .code
Composition.section:referralDetails.code.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:referralDetails.code.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:referralDetails.code.coding
ShortCode defined by a terminology system
Definition

A reference to a code defined by a terminology system.

Cardinality1..1
TypeCoding
SummaryTrue
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
  • rim: CV
  • orim: fhir:Coding rdfs:subClassOf dt:CDCoding
  • v2: C*E.1-8, C*E.10-22
  • rim: union(., ./translation)
  • orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Composition.section:referralDetails.code.coding.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:referralDetails.code.coding.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:referralDetails.code.coding.system
ShortIdentity of the terminology system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Cardinality1..1
Typeuri
SummaryTrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
http://snomed.info/sct
Mappings
  • rim: n/a
  • v2: C*E.3
  • rim: ./codeSystem
  • orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Composition.section:referralDetails.code.coding.version
ShortVersion of the system - if relevant
Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Cardinality0..0
Typestring
SummaryTrue
Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.7
  • rim: ./codeSystemVersion
  • orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
Composition.section:referralDetails.code.coding.code
ShortSymbol in syntax defined by the system
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Cardinality1..1
Typecode
SummaryTrue
Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
886721000000107
Mappings
  • rim: n/a
  • v2: C*E.1
  • rim: ./code
  • orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
Composition.section:referralDetails.code.coding.display
ShortRepresentation defined by the system
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Cardinality1..1
Typestring
SummaryTrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Fixed Value
Referral details
Mappings
  • rim: n/a
  • v2: C*E.2 - but note this is not well followed
  • rim: CV.displayName
  • orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
Composition.section:referralDetails.code.coding.userSelected
ShortIf this coding was chosen directly by the user
Definition

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

Cardinality0..0
Typeboolean
SummaryTrue
Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: Sometimes implied by being first
  • rim: CD.codingRationale
  • orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Composition.section:referralDetails.code.text
ShortPlain text representation of the concept
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Cardinality0..1
Typestring
SummaryTrue
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: C*E.9. But note many systems use C*E.2 for this
  • rim: ./originalText[mediaType/code="text/plain"]/data
  • orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Composition.section:referralDetails.text
ShortText summary of the section, for human interpretation
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.

Cardinality1..1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
  • rim: .text
  • cda: .text
Composition.section:referralDetails.mode
Shortworking | snapshot | changes
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.

Cardinality0..0
Typecode
Binding

The processing mode that applies to this section.

ListMode (required)

ModifierTrue
SummaryTrue
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be mis-understood as a complete list.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
  • cda: n/a
  • w5: class
Composition.section:referralDetails.orderedBy
ShortOrder of section entries
Definition

Specifies the order applied to the items in the section entries.

Cardinality0..0
TypeCodeableConcept
Binding

What order applies to the items in the entry.

List Order Codes (preferred)

Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related 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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
  • cda: n/a
Composition.section:referralDetails.entry
ShortA reference to data that supports this section
Definition

A reference to the actual resource from which the narrative in the section is derived.

Cardinality0..0
TypeReference(CareConnect-Organization-1 | CareConnect-Practitioner-1 | CareConnect-PractitionerRole-1)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
  • cda: .entry
Composition.section:referralDetails.entry.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Comments

Note that FHIR strings may not exceed 1MB in size

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
Composition.section:referralDetails.entry.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Cardinality0..*
TypeExtension
Aliasextensions, user content
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.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:referralDetails.entry.reference
ShortLiteral reference, Relative, internal or absolute URL
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.

Cardinality1..1
Typestring
SummaryTrue
Comments

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, ref-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:referralDetails.entry.identifier
ShortLogical reference, when literal reference is not known
Definition

An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity 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.

Cardinality0..1
TypeIdentifier
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • rim: .identifier
Composition.section:referralDetails.entry.display
ShortText alternative for the resource
Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Cardinality0..1
Typestring
SummaryTrue
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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: N/A
Composition.section:referralDetails.emptyReason
ShortWhy the section is empty
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Cardinality0..0
TypeCodeableConcept
Binding

If a section is empty, why it is empty.

List Empty Reasons (preferred)

Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, cmp-2
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() | (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: .inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]
  • cda: n/a
Composition.section:referralDetails.section
ShortNested Section
Definition

A nested sub-section within this section.

Cardinality0..0
Typesee (section)
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

ConditionsThe cardinality or value of this element may be affected by these constraints: cmp-1
Mappings
  • rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
  • cda: .component.section

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