Package | ihe.pcc.maps |
Type | StructureDefinition |
Id | Id |
FHIR Version | R4 |
Source | https://profiles.ihe.net/PCC/mAPS/https://build.fhir.org/ig/IHE/PCC.mAPS/StructureDefinition-IHE.PCC.mAPS.Composition.html |
Url | https://profiles.ihe.net/PCC/mAPS/StructureDefinition/IHE.PCC.mAPS.Composition |
Version | 1.0.0 |
Status | active |
Date | 2024-10-29T20:32:09+00:00 |
Name | IHE_PCC_mAPS_Composition |
Title | Antapartum Summary |
Experimental | False |
Realm | uv |
Authority | ihe |
Description | Antepartum Summary is a content profile that defines the structure for the aggregation of significant events, diagnoses, and plans of care derived from the visits over the course of an antepartum episode. It is represented in part by Estimated Due Dates and a Visit Summary Flowsheet, in which the aggregated data from the ambulatory office visits is recorded, as well as allergies, advance directives, care plans, and selected histories are provided. The Antepartum Summary represents a summary of the most critical information to an antepartum care provider regarding the status of a patient’s pregnancy. |
Type | Composition |
Kind | resource |
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: StructureDefinition IHE.PCC.mAPS.Composition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
identifier | S | 0..1 | Identifier | Version-independent identifier for the Composition |
status | S | 1..1 | code | preliminary | final | amended | entered-in-error |
type | S | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) |
Slices for coding | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | |
coding:asummary | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 57055-6 | |
Slices for category | S | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this |
category:pstat | 1..1 | CodeableConcept | Categorization of Composition Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 90767-5 | |
subject | S | 1..1 | Reference(PDQm Patient Profile) | Who and/or what the composition is about |
encounter | S | 0..1 | Reference(Encounter) | Context of the Composition |
date | S | 1..1 | dateTime | Composition editing time |
author | S | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
title | S | 1..1 | string | Human Readable name/title Required Pattern: Antepartum Summary |
attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
mode | S | 1..1 | code | personal | professional | legal | official |
time | S | 0..1 | dateTime | When the composition was attested |
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
custodian | S | 0..1 | Reference(Organization) | Organization which maintains the composition |
event | S | 0..* | BackboneElement | The clinical service(s) being documented |
Slices for code | 1..* | CodeableConcept | Code(s) that apply to the event being documented Slice: Unordered, Open by pattern:$this | |
code:obs | 1..1 | CodeableConcept | Code(s) that apply to the event being documented Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v3-ActCode | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: OBS | |
Slices for section | 7..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code | |
section:All Slices | Content/Rules for all slices | |||
title | S | 1..1 | string | Label for section (e.g. for ToC) |
code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:sectionMedications | 1..1 | BackboneElement | Medication Summary Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
entry | S | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference | Medication Statement (IPS) | Medication Request (IPS)) | Medications relevant for the scope of the patient summary |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionAllergies | 1..1 | BackboneElement | Allergies and Intolerances Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
entry | S | 0..* | Reference(AllergyIntolerance | DocumentReference | Allergy Intolerance (IPS)) | Relevant allergies or intolerances (conditions) for that patient. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionProblems | 1..1 | BackboneElement | Problems Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |
entry | S | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Clinical problems or conditions currently being monitored for the patient. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionPastIllnessHx | 1..1 | BackboneElement | History of Past Illness Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
entry | S | 0..* | Reference(Condition | DocumentReference | Condition (IPS)) | Conditions the patient suffered in the past. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionSocialHistory | 0..1 | BackboneElement | Social History Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
entry | S | 0..* | Reference(Observation | DocumentReference | Observation - SH: tobacco use | Observation - SH: alcohol use | Drug Use | Smoking and Tobacco Use Frequency | alcohol Use | Exercise | Diet | Toxic Exposure | Homelessness | At risk of domestic violence | Combat Zone Period | Employment Status | Past Or Present Job | Retirement Date | Usual Work) | Health related 'lifestyle factors' or 'lifestyle observations' (e.g. smoke habits; alcohol consumption; diets, risky habits.) |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionProceduresHx | 1..1 | BackboneElement | History of Procedures Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 47519-4 | |
entry | S | 0..* | Reference(Procedure | DocumentReference | Procedure (IPS)) | Patient past procedures pertinent to the scope of this document. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionPregnancyHx | 1..1 | BackboneElement | History of Pregnancy Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |
entry | S | 0..* | Reference(Observation | DocumentReference | Observation - Pregnancy: status | Observation - Pregnancy: outcome | Multiple Pregnancy | Gestational Age | Date Of Last Menstral Period | Pregnancy History Observations) | Current pregnancy status and, optionally, information about the outcome of earlier pregnancies. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionPlanOfCare | 0..1 | BackboneElement | Plan of Care Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 18776-5 | |
entry | S | 0..* | Reference(CarePlan | DocumentReference) | entry used to represent structured care plans |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionImmunizations | 1..1 | BackboneElement | Immunization Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11369-6 | |
entry | S | 0..* | Reference(Immunization | DocumentReference | Immunization (IPS)) | Patient's immunization status and pertinent history. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionResults | 0..1 | BackboneElement | Results Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
entry | S | 0..* | Reference(Observation | Observation Results (IPS) | DiagnosticReport | DocumentReference | Antepartum Labs | Antepartum Genetic Screenings) | Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionAdvanceDirectives | 0..1 | BackboneElement | Advance Directives Section | |
code | 0..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |