Portuguese Core IG

There are no (further) constraints on this element

Element id

Composition.implicitRules

Short description

A 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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a

language

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.language

Short description

Language of the resource content

Definition

The base language in which the resource is written.

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).

Data type

Binding

IETF language tag

CommonLanguages (preferred)

Binding extensions

maxValueSet	AllLanguages

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a

text

0..1

There are no (further) constraints on this element

Element id

Composition.text

Short description

Text summary of the resource, for human interpretation

Alternate names

narrative, html, xhtml, display

Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
rim: N/A
rim: Act.text?

contained

0..*

Resource

There are no (further) constraints on this element

Element id

Composition.contained

Short description

Contained, inline Resources

Alternate names

inline resources, anonymous resources, contained 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.

Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Data type

Resource

Constraints

dom-r4b: Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems
($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic)

Mappings

rim: Entity. Role, or Act
rim: N/A

extension

0..*

There are no (further) constraints on this element

Element id

Composition.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

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.

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

?! C

0..*

There are no (further) constraints on this element

Element id

Composition.modifierExtension

Short description

Extensions that cannot be ignored

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

identifier

0..1

Element id

Composition.identifier

Short description

An identifier intended for computation

Definition

Identificador da composição/documento por parte do negócio

Comments

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
rim: II - 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
workflow: Event.identifier
w5: FiveWs.identifier
rim: Document.id / Document.setId
cda: .setId
fhirdocumentreference: DocumentReference.masterIdentifier

0..1

There are no (further) constraints on this element

Element id

Composition.identifier.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.identifier.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

use

Σ ?!

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.identifier.use

Short description

usual | official | temp | secondary | old (If known)

Definition

Propósito do identificador:

official: O identificador considerado mais fiável para a identificação do item.

temp: Um identificador temporário.

secondary: Um identificador que foi atribuído para identificar o item em um contexto relativo, mas não pode usado em um contexto diferente.

old: O identificador já não é considerado válido, mas pode ser relevante para fins de pesquisa.

Requirements

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

Comments

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Data type

Binding

IdentifierUse (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
v2: N/A
rim: Role.code or implied by context

type

0..1

There are no (further) constraints on this element

Element id

Composition.identifier.type

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

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

Comments

Value Set: {{link:ValueSet/ExtensionIdentifierType}}

Data type

https://spms.min-saude.pt/iop/valueset/ExtensionIdentifierType (extensible)

Binding

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

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

0..1

There are no (further) constraints on this element

Element id

Composition.identifier.type.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.identifier.type.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

coding

0..*

CodingPTCore

There are no (further) constraints on this element

Element id

Composition.identifier.type.coding

Short description

A reference to a code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

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.

Data type

CodingPTCore

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

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

0..1

Element id

Composition.identifier.type.coding.id

Short description

Unique id for inter-element referencing

Definition

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

Comments

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.identifier.type.coding.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

system

1..1

There are no (further) constraints on this element

Element id

Composition.identifier.type.coding.system

Short description

Identity of the terminology system

Definition

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

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 reference to some definition that establishes the system clearly and unambiguously.

Para sistemas geridos pela SPMS o system deve seguir a seguinte estrutura: http://spms.min-saude.pt/<sistema>/CodeSystem/<system-id>

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..0

There are no (further) constraints on this element

Element id

Composition.identifier.type.coding.version

Short description

Version 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.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

1..1

There are no (further) constraints on this element

Element id

Composition.identifier.type.coding.code

Short description

Symbol 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).

Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

1..1

There are no (further) constraints on this element

Element id

Composition.identifier.type.coding.display

Short description

Representation defined by the system

Definition

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

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 SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

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

userSelected

0..0

boolean

There are no (further) constraints on this element

Element id

Composition.identifier.type.coding.userSelected

Short description

If this coding was chosen directly by the user

Definition

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

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.

Data type

boolean

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

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 ]

text

1..1

There are no (further) constraints on this element

Element id

Composition.identifier.type.text

Short description

Plain 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.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

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

system

0..1

There are no (further) constraints on this element

Element id

Composition.identifier.system

Short description

The namespace for the identifier value

Definition

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

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

Para sistemas geridos pela SPMS o system tem de seguir a seguinte estrutura: http://spms.min-saude.pt/<sistema>/identifiers/<identifier-id>

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Examples
General

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

value

1..1

There are no (further) constraints on this element

Element id

Composition.identifier.value

Short description

The value that is unique

Definition

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

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. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Examples
General

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

period

Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.identifier.period

Short description

Time range defined by start and end date/time

Alternate names

Period

Definition

A time period defined by a start and end date and optionally time.

Comments

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").

Period is not used for a duration (a measure of elapsed time). See Duration.

Data type

Reference(OrganizationPTCore)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
per-1: If present, start SHALL have a lower value than end
start.hasValue().not() or end.hasValue().not() 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

assigner

Σ C

0..0

There are no (further) constraints on this element

Element id

Composition.identifier.assigner

Short description

Organization that issued id (may be just text)

Definition

Organization that issued/manages the identifier.

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.

Data type

Reference(OrganizationPTCore)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)

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

status

Σ ?!

1..1

codeBinding

Element id

Composition.status

Short description

preliminary | final | amended | entered-in-error

Definition

Identifica o status da composição/documento

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.

Data type

Binding

The workflow/clinical status of the composition.

CompositionStatus (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
workflow: Event.status
w5: FiveWs.status
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
fhirdocumentreference: DocumentReference.status

type

1..1

Element id

Composition.type

Short description

Concept - reference to a terminology or just text

Definition

Tipo de composição/documento

Requirements

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

Comments

Value Set Name: Document Type

Data type

https://www.ctc.min-saude.pt/catalogos/apoio-ao-registo-clinico (required)

Binding

Type of a composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
workflow: Event.code
w5: FiveWs.class
rim: ./code
cda: .code
fhirdocumentreference: DocumentReference.type

category

0..*

Element id

Composition.category

Short description

Concept - reference to a terminology or just text

Definition

Categoria

No caso de referenciação, transferência ou requisição identificar a categoria, de acordo com o catálogo CPARADM, ValueSet Service Request Category, codificado em SNOMED CT (“http://snomed.info/sct”). Esta categoria irá permitir a distinção do pedido efetuado.

O catálogo pode ser solicitado ao https://www.ctc.min-saude.pt/

Requirements

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

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Data type

LoincDocumentOntologyInternational (example)

Binding

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

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
workflow: Event.subject
w5: FiveWs.class
rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
cda: n/a
fhirdocumentreference: DocumenttReference.category

subject

Σ C

0..1

Element id

Composition.subject

Short description

A reference from one resource to another

Definition

Sobre quem ou o que é a composição ou documento

Requirements

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

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.

Data type

ReferencePTCore(EncounterPTCore)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.subject[x]
rim: .participation[typeCode="SBJ"].role[typeCode="PAT"]
cda: .recordTarget
fhirdocumentreference: DocumentReference.subject
w5: FiveWs.subject

encounter

Σ C

0..1

Element id

Composition.encounter

Short description

A reference from one resource to another

Definition

Episódio

Requirements

Provides context for the composition and supports searching.

Comments

Data type

ReferencePTCore(EncounterPTCore)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.context
w5: FiveWs.context
rim: unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
cda: .componentOf.encompassingEncounter
fhirdocumentreference: DocumentReference.context.encounter

date

1..1

Element id

Composition.date

Short description

Composition editing time

Definition

Data da composição/documento

O período adota o formato definido pela ISO8601

Requirements

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
workflow: Event.occurrence[x]
w5: FiveWs.done[x]
rim: .effectiveTime[type="TS"]
cda: .effectiveTime
fhirdocumentreference: DocumentReference.content.attachment.date, DocumentReference.created

author

Σ C

1..*

Element id

Composition.author

Short description

A reference from one resource to another

Definition

Responsável pela criação do documento

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor
fhirdocumentreference: DocumentReference.agent

title

1..1

Element id

Composition.title

Short description

Human Readable name/title

Definition

Título do documento

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
rim: ./title
cda: .title
fhirdocumentreference: DocumentReference.description, DocumentReference.content.attachment.title

confidentiality

0..1

codeBinding

Element id

Composition.confidentiality

Short description

As defined by affinity domain

Definition

Nível de confidencialidade do documento

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.

Data type

Binding

Codes specifying the level of confidentiality of the composition.

Confidentiality (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
rim: .confidentialityCode
cda: .confidentialityCode
fhirdocumentreference: DocumentReference.securityLabel

attester

0..*

Element id

Composition.attester

Short description

Attests to accuracy of composition

Definition

Identifica a responsabilidade pela precisão do conteúdo da composição/documento.

Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

0..1

There are no (further) constraints on this element

Element id

Composition.attester.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

mode

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.attester.mode

Short description

personal | professional | legal | official

Definition

The type of attestation the authenticator offers.

Requirements

Indicates the level of authority of the attestation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

CompositionAttestationMode (required)

Binding

The way in which a person authenticated a composition.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

Element id

Composition.attester.time

Short description

When the composition was attested

Definition

Data

A data adota o formato definido pela ISO8601

Requirements

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

Data type

ReferencePTCore(OrganizationPTCore)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

0..1

ReferencePTCore(OrganizationPTCore | PatientPTCore | PractitionerPTCore | PractitionerRolePTCore | https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/RelatedPersonPTCore)

Element id

Composition.attester.party

Short description

A reference from one resource to another

Definition

Pessoa ou entidade que autenticou a composição/documento

Requirements

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

Comments

Data type

ReferencePTCore(OrganizationPTCore | PatientPTCore | PractitionerPTCore | PractitionerRolePTCore | https://spms.min-saude.pt/fhir-r4B/iop/StructureDefinition/RelatedPersonPTCore)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.witness
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

custodian

Σ C

0..1

Element id

Composition.custodian

Short description

A reference from one resource to another

Definition

Entidade responsável pela composição/documento

Requirements

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

Comments

Data type

ReferencePTCore(OrganizationPTCore)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)

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
fhirdocumentreference: DocumentReference.custodian

relatesTo

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo

Short description

Relationships to other compositions/documents

Definition

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

Comments

A document is a version specific composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
rim: .outboundRelationship
cda: .relatedDocument
fhirdocumentreference: DocumentReference.relatesTo

0..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

code

1..1

codeBinding

Element id

Composition.relatesTo.code

Short description

replaces | transforms | signs | appends

Definition

Indica o tipo de relação que esta composição tem com outra composição ou documento

Comments

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

Data type

DocumentRelationshipType (required)

Binding

The type of relationship between documents.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
rim: .outboundRelationship.typeCode
cda: .relatedDocument.typeCode
fhirdocumentreference: DocumentReference.relatesTo.code

target[x]

1..1

Element id

Composition.relatesTo.target[x]

Short description

Target of the relationship

Definition

Composição/documento de destino desse relacionamento.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
rim: .target[classCode="DOC", moodCode="EVN"].id
cda: .relatedDocument.id
fhirdocumentreference: DocumentReference.relatesTo.target

targetIdentifier

Data type

ReferencePTCore(CompositionPTCore)

targetReference

Data type

ReferencePTCore(CompositionPTCore)

event

0..*

Element id

Composition.event

Short description

The clinical service(s) being documented

Definition

Indica o serviço documentado

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
cda: .documentationOf.serviceEvent
fhirdocumentreference: DocumentReference.event

0..1

There are no (further) constraints on this element

Element id

Composition.event.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.event.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

code

0..*

Element id

Composition.event.code

Short description

Concept - reference to a terminology or just text

Definition

Representa os principais atos clínicos.

Usar o system http://terminology.hl7.org/CodeSystem/v3-ActCode

Comments

Data type

Binding

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

ActCode (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .code
cda: .code
fhirdocumentreference: DocumentReference.event.code

period

Σ C

0..1

Element id

Composition.event.period

Short description

Time range defined by start and end date/time

Alternate names

Period

Definition

Período

O período adota o formato definido pela ISO8601

Comments

Period is not used for a duration (a measure of elapsed time). See Duration.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
per-1: If present, start SHALL have a lower value than end
start.hasValue().not() or end.hasValue().not() 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
fhirdocumentreference: DocumentReference.event.period

detail

Σ C

0..*

Element id

Composition.event.detail

Short description

A reference from one resource to another

Definition

Referência do(s) evento(s) que está(ão) sendo documentado(s).

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)

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

section

0..*

There are no (further) constraints on this element

Element id

Composition.section

Short description

Composition is broken into sections

Definition

The root of the sections that make up the composition.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
cmp-1: A section must contain at least one of text, entries, or sub-sections
text.exists() or entry.exists() or section.exists()
cmp-2: A section can only have an emptyReason if it is empty
emptyReason.empty() or entry.empty()

Mappings

rim: n/a
rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

0..1

There are no (further) constraints on this element

Element id

Composition.section.id

Short description

Unique id for inter-element referencing

Definition

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

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

title

0..1

Element id

Composition.section.title

Short description

Label for section (e.g. for ToC)

Alternate names

header, label, caption

Definition

Título da secção

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.

Data type

DocumentSectionCodes (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
rim: ./title
cda: .title

code

0..1

CodeableConcept

Element id

Composition.section.code

Short description

Classification of section (recommended)

Definition

Identifica o tipo de conteúdo presente na secção

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.

Data type

CodeableConcept

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: ./code
cda: .code

author

0..*

Element id

Composition.section.author

Short description

A reference from one resource to another

Definition

Indica o responsável pelas informações nesta secção, não necessariamente quem as digitou.

Requirements

Identifies who is responsible for the content.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

Element id

Composition.section.focus

Short description

A reference from one resource to another

Definition

O foco real da secção quando esta não é o mesmo assunto da composição

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
cda: .subject? (CDA did not differentiate between subject and focus)

text

0..1

Element id

Composition.section.text

Short description

Text summary of the section, for human interpretation

Definition

Uma narrativa que contém o conteúdo da secção

Comments

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

Data type

Conditions

The 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 unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
rim: N/A
rim: .text
cda: .text

mode

0..1

codeBinding

Element id

Composition.section.mode

Short description

working | snapshot | changes

Definition

Como a lista foi preparada

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 misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

ListMode (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

Mappings

rim: n/a
w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

Element id

Composition.section.orderedBy

Short description

Concept - reference to a terminology or just text

Definition

Especifica a ordem aplicada aos itens nas entradas da secção.

Usar o system http://terminology.hl7.org/CodeSystem/list-order

Requirements

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

Comments

Data type

Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters

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

entry

0..*

Element id

Composition.section.entry

Short description

A reference from one resource to another

Definition

Referência aos recursos que suportam esta secção

Comments

Data type

Conditions

The 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 unless an empty Parameters resource
hasValue() or (children().count() > id.count()) or $this is Parameters
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource)

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

emptyReason

0..1

Element id

Composition.section.emptyReason

Short description

Concept - reference to a terminology or just text

Definition

Indica o motivo pelo qual a secção está vazia

Usar o system ttp://terminology.hl7.org/CodeSystem/list-empty-reason

Requirements

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

Comments

Data type