Package | ihe.pcc.mpsc |
Type | StructureDefinition |
Id | Id |
FHIR Version | R4 |
Source | https://profiles.ihe.net/PCC/mPSC/https://build.fhir.org/ig/IHE/PCC.PCS/StructureDefinition-IHE.PCC.mPSC.Composition.ClinicalSubset.html |
Url | https://profiles.ihe.net/PCC/mPSC/StructureDefinition/IHE.PCC.mPSC.Composition.ClinicalSubset |
Version | 2.0.0-draft |
Status | draft |
Date | 2024-09-03T15:04:24+00:00 |
Name | IHE_PCC_mPSC_Composition_ClinicalSubset |
Title | Paramedicince Summary Composition Clinical Subset |
Experimental | False |
Realm | uv |
Authority | ihe |
Description | The composition of the FHIR elements that are used to build the FHIR Document for the Paramedicine Care Summary Clinical Subset the following cardinalities follow the documentation in the PCS profile: - RE 0..1 IPS Advance Directives - RE 0..1 IPS History of Past Illness - RE 0..1 IPS History of Procedures - R 1..1 IPS Allergies and Intolerances - R 1..1 IPS Medications - R 0..1 IPS Problems (complaints?) --- review of systems - R 1..1 IPS Functional Status - RE 0..1 Medications Administered Section ---- procedures performed - RE 0..1 IPS Vital Signs - O 0..1 Payor - RE 0..1 IPS History of Pregnancy - O 0..1 Immunizations - O 0..1 IPS Medical Devices - O 0..1 IPS Results - O 0..1 IPS Plan of Care - O 0..1 Payor - O 0..1 InjuryEvent seciton - O 0..1 eArrest Section ------- mass casuality incident |
Type | Composition |
Kind | resource |
StructureDefinition | |
IHE.PCC.mPSC.Composition.Complete.Report | Paramedicince Summary Composition Clinical Subset |
Note: links and images are rebased to the (stated) source
Generated Narrative: StructureDefinition IHE.PCC.mPSC.Composition.ClinicalSubset
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Clinical Document | A set of resources composed into a single coherent clinical statement with clinical attestation | |
language | S | 1..1 | code | Language of the resource content Binding: CommonLanguages (preferred) |
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
Slices for extension | Content/Rules for all slices | |||
participant_extension | S | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Extension URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension |
identifier | S | 1..1 | Identifier | Version-independent identifier for the Composition |
type | S | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) |
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: 34133-9 | |
subject | S | 1..1 | Reference(Paramedicine Patient) | Who and/or what the composition is about |
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 |
confidentiality | 1..1 | code | As defined by affinity domain | |
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 |
Slices for event | 1..* | BackboneElement | The clinical service(s) being documented Slice: Unordered, Open by value:code | |
event:careProvisioningEvent | S | 0..1 | BackboneElement | The clinical service(s) being documented |
code | S | 1..1 | CodeableConcept | Code(s) that apply to the event being documented |
period | S | 0..1 | Period | The period covered by the documentation |
Slices for section | 7..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by pattern:code | |
section:All Slices | Content/Rules for all slices | |||
code | S | 1..1 | CodeableConcept | Classification of section (recommended) |
text | S | 1..1 | Narrative | Text summary of the section, for human interpretation |
section:sectionDetailedChiefComplaint | S | 1..1 | BackboneElement | Chief Complaint 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: 10154-3 | |
Slices for entry | 0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section Slice: Unordered, Open by pattern:reference | |
entry:chiefComplaintObservations | S | 0..* | Reference(Observation) | A reference to data that supports this section |
entry:chiefComplaint | 0..1 | Reference(Condition (IPS)) | A reference to data that supports this section | |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionCodedReasonforVisit | S | 1..1 | BackboneElement | section Reason for Visit 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: 29299-5 | |
entry | S | 0..* | Reference(Condition | DocumentReference | Observation) | A reference to data that supports this section |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionPresentIllnessHx | S | 1..1 | BackboneElement | IHE History of Present 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: 10164-2 | |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionProblems | S | 1..1 | BackboneElement | IHE Active 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 | |
Slices for entry | S | 0..* | Reference(Condition | DocumentReference) | Problem Concern Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:problem | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section | |
emptyReason | S | 0..1 | CodeableConcept | Why the section is empty |
section:sectionMedications | S | 1..1 | BackboneElement | IHE Medications 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 | |
Slices for entry | S | 0..* | Reference(MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference) | Medications Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:medicationStatement | 0..* | Reference(Medication Statement (IPS)) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:medicationRequest | 0..* | Reference(Medication Request (IPS)) | A reference to data that supports this section | |
section:sectionAllergies | S | 1..1 | BackboneElement | IHE Allergies and Other Adverse Reactions 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 | |
Slices for entry | S | 0..* | Reference(AllergyIntolerance | DocumentReference) | Allergy or Intolerance Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:allergyOrIntolerance | 0..* | Reference(Allergy Intolerance (IPS)) | A reference to data that supports this section | |
section:sectionPastIllnessHx | S | 0..1 | BackboneElement | IHE 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 | |
Slices for entry | 0..* | Reference(Condition | DocumentReference) | Conditions Slice: Unordered, Open by pattern:reference | |
Slices for entry | Content/Rules for all slices | |||
entry:pastProblem | 0..* | Reference(Condition (IPS)) | A reference to data that supports this section | |
section:sectionProceduresHx | S | 0..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 | |
Slices for entry | S | 0..* | Reference(Procedure | DocumentReference) | Past procedures Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:procedure | 0..* | Reference(Procedure (IPS)) | A reference to data that supports this section | |
section:sectionImmunizations | S | 0..1 | BackboneElement | IHE Immunizations 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 | |
Slices for entry | S | 0..* | Reference(Immunization | MedicationAdministration | DocumentReference) | Immunizations Entry Slice: Unordered, Open by pattern:reference |
Slices for entry | Content/Rules for all slices | |||
entry:immunization | 0..* | Reference(Immunization (IPS)) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:immunizationAdministration | 0..* | Reference(MedicationAdministration) | A reference to data that supports this section | |
section:sectionSocialHistory | S | 0..1 | BackboneElement | IHE 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 | |
Slices for entry | 0..* | Reference(Observation | DocumentReference) | Social History Entry Slice: Unordered, Open by pattern:reference | |
Slices for entry | Content/Rules for all slices | |||
entry:smokingTobaccoUse | 0..* | Reference(Observation - SH: tobacco use) | A reference to data that supports this section | |
Slices for entry | Content/Rules for all slices | |||
entry:alcoholUse | 0..* | Reference(Observation - SH: alcohol use) | A reference to data that supports this section | |