Guía de Implementación "cl core" FHIR R4, (Versión Evolutiva)
1.8.0 - ci-build Chile flag

This page is part of the Chile Core (v1.8.0: STU2 Draft) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Resource Profile: CL Documento

Official URL: https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/DocumentoCl Version: 1.8.0
Active as of 2023-06-23 Computable Name: DocumentoCl

Copyright/Legal: Usado con el permiso de HL7 International, todos los derechos resevados en los Licencias de HL7 Internacional.

Definición de un documento para Resumen de Historia o Registro de Encuentro para Historia Clínica, basado en IPS.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... identifier S0..1IdentifierIdentificador local para recurso de documeto que puede ser distinto para cada versión del mismo
... status S1..1codeEstado, valores posibles: preliminary | final | amended | entered-in-error
Required Pattern: final
... type S1..1CodeableConceptTipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (required)
.... reference S1..1stringCorresponde al paciente
... encounter S0..1Reference(Encounter)Contexto del Documento.
.... reference S1..1stringCorresponde al paciente
.... identifier S0..1IdentifierIdentificador, en formato identifier para el encuentro
.... display S0..1stringtexto que describe el contexto del documento
... date S1..1dateTimeFecha en la cual se editó el documento
... author S1..1Reference(Practitioner)Quien Ha creado el documento
... title S1..1stringTítulo del documento generado
... attester S0..*BackboneElementValidadores del documento
.... mode S1..1codeLabor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required)
.... time S0..1dateTimeFecha y Hora de la validación
.... party S0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Quien validó
... Slices for section S1..*BackboneElementSección del documento
Slice: Unordered, Open by pattern:code
.... section:All Slices Content/Rules for all slices
..... code S1..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example)
.... section:sectionDiagnosticos S0..*BackboneElementSección Diagnósticos
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11450-4
..... entry S1..*Reference(Condition)Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente.
Slice: Unordered, Open by profile:resolve()
.... section:sectionMedicamentos S0..*BackboneElementSección Medicamentos
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10160-0
..... entry S1..*Reference(MedicationStatement)Referencia al Medicamento Prescrito al paciente.
Slice: Unordered, Open by profile:resolve()
.... section:sectionAlergias S0..*BackboneElementSección Alergias y Reacciones Adversas
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
..... entry S1..*Reference(AllergyIntolerance)Alergias e Intolerancia descrita
Slice: Unordered, Open by profile:resolve()
.... section:sectionObservacionEmbarazo S0..*BackboneElementSección Antecedentes de Embarazo
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10162-6
..... entry S1..*Reference(Observation)Descripción del antecedente de embarzo
Slice: Unordered, Open by profile:resolve()
.... section:sectionObservacionSignosVitales S0..*BackboneElementSección de Signos Vitales Medidos
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8716-3
..... entry S1..*Reference(Observation)Descripción del los signos vitales y mediciones desarrolladas
Slice: Unordered, Open by profile:resolve()

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Composition.typerequiredVSTiposDocClinic (a valid code from LOINC)
Composition.attester.moderequiredCompositionAttestationMode
Composition.section.codeexampleDocumentSectionCodes
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..1IdentifierIdentificador local para recurso de documeto que puede ser distinto para cada versión del mismo
... type SΣ1..1CodeableConceptTipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (required)
... subject SΣ1..1Reference(Patient)Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno.
.... reference SΣC1..1stringCorresponde al paciente
... encounter SΣ0..1Reference(Encounter)Contexto del Documento.
.... reference SΣC1..1stringCorresponde al paciente
.... identifier SΣ0..1IdentifierIdentificador, en formato identifier para el encuentro
.... display SΣ0..1stringtexto que describe el contexto del documento
... date SΣ1..1dateTimeFecha en la cual se editó el documento
... author SΣ1..1Reference(Practitioner)Quien Ha creado el documento
... title SΣ1..1stringTítulo del documento generado
... attester S0..*BackboneElementValidadores del documento
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode S1..1codeLabor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required)
.... time S0..1dateTimeFecha y Hora de la validación
.... party S0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Quien validó
... Slices for section SC1..*BackboneElementSección del documento
Slice: Unordered, Open by pattern:code
.... section:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... code S1..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example)
.... section:sectionDiagnosticos SC0..*BackboneElementSección Diagnósticos
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11450-4
..... entry SC1..*Reference(Condition)Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente.
.... section:sectionMedicamentos SC0..*BackboneElementSección Medicamentos
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10160-0
..... entry SC1..*Reference(MedicationStatement)Referencia al Medicamento Prescrito al paciente.
.... section:sectionAlergias SC0..*BackboneElementSección Alergias y Reacciones Adversas
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
..... entry SC1..*Reference(AllergyIntolerance)Alergias e Intolerancia descrita
.... section:sectionObservacionEmbarazo SC0..*BackboneElementSección Antecedentes de Embarazo
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10162-6
..... entry SC1..*Reference(Observation)Descripción del antecedente de embarzo
.... section:sectionObservacionSignosVitales SC0..*BackboneElementSección de Signos Vitales Medidos
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8716-3
..... entry SC1..*Reference(Observation)Descripción del los signos vitales y mediciones desarrolladas

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Composition.statusrequiredPattern: final
Composition.typerequiredVSTiposDocClinic (a valid code from LOINC)
Composition.attester.moderequiredCompositionAttestationMode
Composition.section.codeexampleDocumentSectionCodes
Composition.section:sectionDiagnosticos.codeexamplePattern: LOINC code 11450-4
Composition.section:sectionMedicamentos.codeexamplePattern: LOINC code 10160-0
Composition.section:sectionAlergias.codeexamplePattern: LOINC code 48765-2
Composition.section:sectionObservacionEmbarazo.codeexamplePattern: LOINC code 10162-6
Composition.section:sectionObservacionSignosVitales.codeexamplePattern: LOINC code 8716-3
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..1IdentifierIdentificador local para recurso de documeto que puede ser distinto para cada versión del mismo
... status ?!SΣ1..1codeEstado, valores posibles: preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.


Required Pattern: final
... type SΣ1..1CodeableConceptTipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (required)
... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(Patient)Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC1..1stringCorresponde al paciente
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... encounter SΣ0..1Reference(Encounter)Contexto del Documento.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC1..1stringCorresponde al paciente
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier SΣ0..1IdentifierIdentificador, en formato identifier para el encuentro
.... display SΣ0..1stringtexto que describe el contexto del documento
... date SΣ1..1dateTimeFecha en la cual se editó el documento
... author SΣ1..1Reference(Practitioner)Quien Ha creado el documento
... title SΣ1..1stringTítulo del documento generado
... confidentiality Σ0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

... attester S0..*BackboneElementValidadores del documento
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode S1..1codeLabor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required)
.... time S0..1dateTimeFecha y Hora de la validación
.... party S0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Quien validó
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... Slices for section SC1..*BackboneElementSección del documento
Slice: Unordered, Open by pattern:code
.... section:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example)
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry C0..*Reference(Resource)A reference to data that supports this section
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section
.... section:sectionDiagnosticos SC0..*BackboneElementSección Diagnósticos
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11450-4
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SC1..*Reference(Condition)Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente.
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section
.... section:sectionMedicamentos SC0..*BackboneElementSección Medicamentos
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10160-0
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SC1..*Reference(MedicationStatement)Referencia al Medicamento Prescrito al paciente.
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section
.... section:sectionAlergias SC0..*BackboneElementSección Alergias y Reacciones Adversas
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SC1..*Reference(AllergyIntolerance)Alergias e Intolerancia descrita
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section
.... section:sectionObservacionEmbarazo SC0..*BackboneElementSección Antecedentes de Embarazo
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10162-6
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SC1..*Reference(Observation)Descripción del antecedente de embarzo
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section
.... section:sectionObservacionSignosVitales SC0..*BackboneElementSección de Signos Vitales Medidos
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8716-3
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SC1..*Reference(Observation)Descripción del los signos vitales y mediciones desarrolladas
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredPattern: final
Composition.typerequiredVSTiposDocClinic (a valid code from LOINC)
Composition.categoryexampleDocumentClassValueSet
Composition.subject.typeextensibleResourceType
Composition.encounter.typeextensibleResourceType
Composition.confidentialityrequiredv3.ConfidentialityClassification
Composition.attester.moderequiredCompositionAttestationMode
Composition.relatesTo.coderequiredDocumentRelationshipType
Composition.event.codeexampleActCode
Composition.section.codeexampleDocumentSectionCodes
Composition.section.moderequiredListMode
Composition.section.orderedBypreferredListOrderCodes
Composition.section.emptyReasonpreferredListEmptyReasons
Composition.section:sectionDiagnosticos.codeexamplePattern: LOINC code 11450-4
Composition.section:sectionDiagnosticos.moderequiredListMode
Composition.section:sectionDiagnosticos.orderedBypreferredListOrderCodes
Composition.section:sectionDiagnosticos.emptyReasonpreferredListEmptyReasons
Composition.section:sectionMedicamentos.codeexamplePattern: LOINC code 10160-0
Composition.section:sectionMedicamentos.moderequiredListMode
Composition.section:sectionMedicamentos.orderedBypreferredListOrderCodes
Composition.section:sectionMedicamentos.emptyReasonpreferredListEmptyReasons
Composition.section:sectionAlergias.codeexamplePattern: LOINC code 48765-2
Composition.section:sectionAlergias.moderequiredListMode
Composition.section:sectionAlergias.orderedBypreferredListOrderCodes
Composition.section:sectionAlergias.emptyReasonpreferredListEmptyReasons
Composition.section:sectionObservacionEmbarazo.codeexamplePattern: LOINC code 10162-6
Composition.section:sectionObservacionEmbarazo.moderequiredListMode
Composition.section:sectionObservacionEmbarazo.orderedBypreferredListOrderCodes
Composition.section:sectionObservacionEmbarazo.emptyReasonpreferredListEmptyReasons
Composition.section:sectionObservacionSignosVitales.codeexamplePattern: LOINC code 8716-3
Composition.section:sectionObservacionSignosVitales.moderequiredListMode
Composition.section:sectionObservacionSignosVitales.orderedBypreferredListOrderCodes
Composition.section:sectionObservacionSignosVitales.emptyReasonpreferredListEmptyReasons

This structure is derived from Composition

Summary

Mandatory: 4 elements (11 nested mandatory elements)
Must-Support: 33 elements

Slices

This structure defines the following Slices:

  • The element Composition.section is sliced based on the value of pattern:code
  • The element Composition.section.entry is sliced based on the value of profile:resolve()

Differential View

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... identifier S0..1IdentifierIdentificador local para recurso de documeto que puede ser distinto para cada versión del mismo
... status S1..1codeEstado, valores posibles: preliminary | final | amended | entered-in-error
Required Pattern: final
... type S1..1CodeableConceptTipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (required)
.... reference S1..1stringCorresponde al paciente
... encounter S0..1Reference(Encounter)Contexto del Documento.
.... reference S1..1stringCorresponde al paciente
.... identifier S0..1IdentifierIdentificador, en formato identifier para el encuentro
.... display S0..1stringtexto que describe el contexto del documento
... date S1..1dateTimeFecha en la cual se editó el documento
... author S1..1Reference(Practitioner)Quien Ha creado el documento
... title S1..1stringTítulo del documento generado
... attester S0..*BackboneElementValidadores del documento
.... mode S1..1codeLabor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required)
.... time S0..1dateTimeFecha y Hora de la validación
.... party S0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Quien validó
... Slices for section S1..*BackboneElementSección del documento
Slice: Unordered, Open by pattern:code
.... section:All Slices Content/Rules for all slices
..... code S1..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example)
.... section:sectionDiagnosticos S0..*BackboneElementSección Diagnósticos
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11450-4
..... entry S1..*Reference(Condition)Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente.
Slice: Unordered, Open by profile:resolve()
.... section:sectionMedicamentos S0..*BackboneElementSección Medicamentos
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10160-0
..... entry S1..*Reference(MedicationStatement)Referencia al Medicamento Prescrito al paciente.
Slice: Unordered, Open by profile:resolve()
.... section:sectionAlergias S0..*BackboneElementSección Alergias y Reacciones Adversas
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
..... entry S1..*Reference(AllergyIntolerance)Alergias e Intolerancia descrita
Slice: Unordered, Open by profile:resolve()
.... section:sectionObservacionEmbarazo S0..*BackboneElementSección Antecedentes de Embarazo
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10162-6
..... entry S1..*Reference(Observation)Descripción del antecedente de embarzo
Slice: Unordered, Open by profile:resolve()
.... section:sectionObservacionSignosVitales S0..*BackboneElementSección de Signos Vitales Medidos
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8716-3
..... entry S1..*Reference(Observation)Descripción del los signos vitales y mediciones desarrolladas
Slice: Unordered, Open by profile:resolve()

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Composition.typerequiredVSTiposDocClinic (a valid code from LOINC)
Composition.attester.moderequiredCompositionAttestationMode
Composition.section.codeexampleDocumentSectionCodes

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..1IdentifierIdentificador local para recurso de documeto que puede ser distinto para cada versión del mismo
... type SΣ1..1CodeableConceptTipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (required)
... subject SΣ1..1Reference(Patient)Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno.
.... reference SΣC1..1stringCorresponde al paciente
... encounter SΣ0..1Reference(Encounter)Contexto del Documento.
.... reference SΣC1..1stringCorresponde al paciente
.... identifier SΣ0..1IdentifierIdentificador, en formato identifier para el encuentro
.... display SΣ0..1stringtexto que describe el contexto del documento
... date SΣ1..1dateTimeFecha en la cual se editó el documento
... author SΣ1..1Reference(Practitioner)Quien Ha creado el documento
... title SΣ1..1stringTítulo del documento generado
... attester S0..*BackboneElementValidadores del documento
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode S1..1codeLabor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required)
.... time S0..1dateTimeFecha y Hora de la validación
.... party S0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Quien validó
... Slices for section SC1..*BackboneElementSección del documento
Slice: Unordered, Open by pattern:code
.... section:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... code S1..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example)
.... section:sectionDiagnosticos SC0..*BackboneElementSección Diagnósticos
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11450-4
..... entry SC1..*Reference(Condition)Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente.
.... section:sectionMedicamentos SC0..*BackboneElementSección Medicamentos
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10160-0
..... entry SC1..*Reference(MedicationStatement)Referencia al Medicamento Prescrito al paciente.
.... section:sectionAlergias SC0..*BackboneElementSección Alergias y Reacciones Adversas
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
..... entry SC1..*Reference(AllergyIntolerance)Alergias e Intolerancia descrita
.... section:sectionObservacionEmbarazo SC0..*BackboneElementSección Antecedentes de Embarazo
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10162-6
..... entry SC1..*Reference(Observation)Descripción del antecedente de embarzo
.... section:sectionObservacionSignosVitales SC0..*BackboneElementSección de Signos Vitales Medidos
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8716-3
..... entry SC1..*Reference(Observation)Descripción del los signos vitales y mediciones desarrolladas

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Composition.statusrequiredPattern: final
Composition.typerequiredVSTiposDocClinic (a valid code from LOINC)
Composition.attester.moderequiredCompositionAttestationMode
Composition.section.codeexampleDocumentSectionCodes
Composition.section:sectionDiagnosticos.codeexamplePattern: LOINC code 11450-4
Composition.section:sectionMedicamentos.codeexamplePattern: LOINC code 10160-0
Composition.section:sectionAlergias.codeexamplePattern: LOINC code 48765-2
Composition.section:sectionObservacionEmbarazo.codeexamplePattern: LOINC code 10162-6
Composition.section:sectionObservacionSignosVitales.codeexamplePattern: LOINC code 8716-3

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..1IdentifierIdentificador local para recurso de documeto que puede ser distinto para cada versión del mismo
... status ?!SΣ1..1codeEstado, valores posibles: preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.


Required Pattern: final
... type SΣ1..1CodeableConceptTipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (required)
... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(Patient)Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC1..1stringCorresponde al paciente
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... encounter SΣ0..1Reference(Encounter)Contexto del Documento.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC1..1stringCorresponde al paciente
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier SΣ0..1IdentifierIdentificador, en formato identifier para el encuentro
.... display SΣ0..1stringtexto que describe el contexto del documento
... date SΣ1..1dateTimeFecha en la cual se editó el documento
... author SΣ1..1Reference(Practitioner)Quien Ha creado el documento
... title SΣ1..1stringTítulo del documento generado
... confidentiality Σ0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

... attester S0..*BackboneElementValidadores del documento
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode S1..1codeLabor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required)
.... time S0..1dateTimeFecha y Hora de la validación
.... party S0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Quien validó
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... Slices for section SC1..*BackboneElementSección del documento
Slice: Unordered, Open by pattern:code
.... section:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title 0..1stringLabel for section (e.g. for ToC)
..... code S1..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example)
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry C0..*Reference(Resource)A reference to data that supports this section
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section
.... section:sectionDiagnosticos SC0..*BackboneElementSección Diagnósticos
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11450-4
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SC1..*Reference(Condition)Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente.
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section
.... section:sectionMedicamentos SC0..*BackboneElementSección Medicamentos
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10160-0
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SC1..*Reference(MedicationStatement)Referencia al Medicamento Prescrito al paciente.
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section
.... section:sectionAlergias SC0..*BackboneElementSección Alergias y Reacciones Adversas
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 48765-2
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SC1..*Reference(AllergyIntolerance)Alergias e Intolerancia descrita
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section
.... section:sectionObservacionEmbarazo SC0..*BackboneElementSección Antecedentes de Embarazo
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 10162-6
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SC1..*Reference(Observation)Descripción del antecedente de embarzo
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section
.... section:sectionObservacionSignosVitales SC0..*BackboneElementSección de Signos Vitales Medidos
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... title S1..1stringLabel for section (e.g. for ToC)
..... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8716-3
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
..... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
..... text C0..1NarrativeText summary of the section, for human interpretation
..... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

..... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

..... entry SC1..*Reference(Observation)Descripción del los signos vitales y mediciones desarrolladas
..... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

..... section C0..*See section (Composition)Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredPattern: final
Composition.typerequiredVSTiposDocClinic (a valid code from LOINC)
Composition.categoryexampleDocumentClassValueSet
Composition.subject.typeextensibleResourceType
Composition.encounter.typeextensibleResourceType
Composition.confidentialityrequiredv3.ConfidentialityClassification
Composition.attester.moderequiredCompositionAttestationMode
Composition.relatesTo.coderequiredDocumentRelationshipType
Composition.event.codeexampleActCode
Composition.section.codeexampleDocumentSectionCodes
Composition.section.moderequiredListMode
Composition.section.orderedBypreferredListOrderCodes
Composition.section.emptyReasonpreferredListEmptyReasons
Composition.section:sectionDiagnosticos.codeexamplePattern: LOINC code 11450-4
Composition.section:sectionDiagnosticos.moderequiredListMode
Composition.section:sectionDiagnosticos.orderedBypreferredListOrderCodes
Composition.section:sectionDiagnosticos.emptyReasonpreferredListEmptyReasons
Composition.section:sectionMedicamentos.codeexamplePattern: LOINC code 10160-0
Composition.section:sectionMedicamentos.moderequiredListMode
Composition.section:sectionMedicamentos.orderedBypreferredListOrderCodes
Composition.section:sectionMedicamentos.emptyReasonpreferredListEmptyReasons
Composition.section:sectionAlergias.codeexamplePattern: LOINC code 48765-2
Composition.section:sectionAlergias.moderequiredListMode
Composition.section:sectionAlergias.orderedBypreferredListOrderCodes
Composition.section:sectionAlergias.emptyReasonpreferredListEmptyReasons
Composition.section:sectionObservacionEmbarazo.codeexamplePattern: LOINC code 10162-6
Composition.section:sectionObservacionEmbarazo.moderequiredListMode
Composition.section:sectionObservacionEmbarazo.orderedBypreferredListOrderCodes
Composition.section:sectionObservacionEmbarazo.emptyReasonpreferredListEmptyReasons
Composition.section:sectionObservacionSignosVitales.codeexamplePattern: LOINC code 8716-3
Composition.section:sectionObservacionSignosVitales.moderequiredListMode
Composition.section:sectionObservacionSignosVitales.orderedBypreferredListOrderCodes
Composition.section:sectionObservacionSignosVitales.emptyReasonpreferredListEmptyReasons

This structure is derived from Composition

Summary

Mandatory: 4 elements (11 nested mandatory elements)
Must-Support: 33 elements

Slices

This structure defines the following Slices:

  • The element Composition.section is sliced based on the value of pattern:code
  • The element Composition.section.entry is sliced based on the value of profile:resolve()

 

Other representations of profile: CSV, Excel, Schematron