Guía de Implementación "cl core" FHIR R4, (Versión Evolutiva)
1.8.2 - ci-build
Guía de Implementación "cl core" FHIR R4, (Versión Evolutiva)
1.8.2 - ci-build
This page is part of the Chile Core (v1.8.2: STU2 Draft) based on FHIR R4. . For a full list of available versions, see the Directory of published versions 
| Official URL: https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/DocumentoCl | Version: 1.8.2 | |||
| Active as of 2023-09-01 | Computable Name: DocumentoCl | |||
Copyright/Legal: Usado con el permiso de HL7 International, todos los derechos resevados en los Licencias de HL7 Internacional. |
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Definición de un documento para Resumen de Historia o Registro de Encuentro para Historia Clínica, basado en IPS.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  identifier | S | 0..1 | Identifier | Identificador local para recurso de documeto que puede ser distinto para cada versión del mismo |
| status | S | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Required Pattern: final |
| type | S | 1..1 | CodeableConcept | Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (required) |
  subject | S | 1..1 | Reference(Patient) | Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno. |
  reference | S | 1..1 | string | Corresponde al paciente |
| encounter | S | 0..1 | Reference(Encounter) | Contexto del Documento. |
| reference | S | 1..1 | string | Corresponde al paciente |
| identifier | S | 0..1 | Identifier | Identificador, en formato identifier para el encuentro |
| display | S | 0..1 | string | texto que describe el contexto del documento |
| date | S | 1..1 | dateTime | Fecha en la cual se editó el documento |
| author | S | 1..1 | Reference(Practitioner) | Quien Ha creado el documento |
| title | S | 1..1 | string | Título del documento generado |
| attester | S | 0..* | BackboneElement | Validadores del documento |
| mode | S | 1..1 | code | Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required) |
| time | S | 0..1 | dateTime | Fecha y Hora de la validación |
| party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Quien validó |
  Slices for section | S | 1..* | BackboneElement | Sección del documento Slice: Unordered, Open by pattern:code |
  section:All Slices | Content/Rules for all slices | |||
  code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
 section:sectionDiagnosticos | S | 0..* | BackboneElement | Sección Diagnósticos |
 title | S | 1..1 | string | Label for section (e.g. for ToC) |
 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 | 1..* | Reference(Condition) | Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente. Slice: Unordered, Open by profile:resolve() |
| section:sectionMedicamentos | S | 0..* | BackboneElement | Sección Medicamentos |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| 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 | 1..* | Reference(MedicationStatement) | Referencia al Medicamento Prescrito al paciente. Slice: Unordered, Open by profile:resolve() |
| section:sectionAlergias | S | 0..* | BackboneElement | Sección Alergias y Reacciones Adversas |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| 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 | 1..* | Reference(AllergyIntolerance) | Alergias e Intolerancia descrita Slice: Unordered, Open by profile:resolve() |
| section:sectionObservacionEmbarazo | S | 0..* | BackboneElement | Sección Antecedentes de Embarazo |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| 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 | 1..* | Reference(Observation) | Descripción del antecedente de embarzo Slice: Unordered, Open by profile:resolve() |
 section:sectionObservacionSignosVitales | S | 0..* | BackboneElement | Sección de Signos Vitales Medidos |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| 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: 8716-3 | |
| entry | S | 1..* | Reference(Observation) | Descripción del los signos vitales y mediciones desarrolladas Slice: Unordered, Open by profile:resolve() |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Composition.type | required | VSTiposDocClinic (a valid code from LOINC) |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.section.code | example | DocumentSectionCodes |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
 identifier | SΣ | 0..1 | Identifier | Identificador local para recurso de documeto que puede ser distinto para cada versión del mismo |
| status | ?!SΣ | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. Required Pattern: final |
| type | SΣ | 1..1 | CodeableConcept | Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (required) |
| subject | SΣ | 1..1 | Reference(Patient) | Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno. |
| reference | SΣC | 1..1 | string | Corresponde al paciente |
| encounter | SΣ | 0..1 | Reference(Encounter) | Contexto del Documento. |
| reference | SΣC | 1..1 | string | Corresponde al paciente |
| identifier | SΣ | 0..1 | Identifier | Identificador, en formato identifier para el encuentro |
| display | SΣ | 0..1 | string | texto que describe el contexto del documento |
| date | SΣ | 1..1 | dateTime | Fecha en la cual se editó el documento |
| author | SΣ | 1..1 | Reference(Practitioner) | Quien Ha creado el documento |
| title | SΣ | 1..1 | string | Título del documento generado |
| attester | S | 0..* | BackboneElement | Validadores del documento |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | S | 1..1 | code | Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required) |
| time | S | 0..1 | dateTime | Fecha y Hora de la validación |
| party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Quien validó |
| Slices for section | SC | 1..* | BackboneElement | Sección del documento Slice: Unordered, Open by pattern:code |
| section:All Slices | Content/Rules for all slices | |||
 modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| section:sectionDiagnosticos | SC | 0..* | BackboneElement | Sección Diagnósticos |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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 | SC | 1..* | Reference(Condition) | Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente. |
| section:sectionMedicamentos | SC | 0..* | BackboneElement | Sección Medicamentos |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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 | SC | 1..* | Reference(MedicationStatement) | Referencia al Medicamento Prescrito al paciente. |
| section:sectionAlergias | SC | 0..* | BackboneElement | Sección Alergias y Reacciones Adversas |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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 | SC | 1..* | Reference(AllergyIntolerance) | Alergias e Intolerancia descrita |
| section:sectionObservacionEmbarazo | SC | 0..* | BackboneElement | Sección Antecedentes de Embarazo |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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 | SC | 1..* | Reference(Observation) | Descripción del antecedente de embarzo |
| section:sectionObservacionSignosVitales | SC | 0..* | BackboneElement | Sección de Signos Vitales Medidos |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 8716-3 | |
| entry | SC | 1..* | Reference(Observation) | Descripción del los signos vitales y mediciones desarrolladas |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Composition.status | required | Pattern: final |
| Composition.type | required | VSTiposDocClinic (a valid code from LOINC) |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.section.code | example | DocumentSectionCodes |
| Composition.section:sectionDiagnosticos.code | example | Pattern: LOINC code 11450-4 |
| Composition.section:sectionMedicamentos.code | example | Pattern: LOINC code 10160-0 |
| Composition.section:sectionAlergias.code | example | Pattern: LOINC code 48765-2 |
| Composition.section:sectionObservacionEmbarazo.code | example | Pattern: LOINC code 10162-6 |
| Composition.section:sectionObservacionSignosVitales.code | example | Pattern: LOINC code 8716-3 |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣ | 0..1 | Identifier | Identificador local para recurso de documeto que puede ser distinto para cada versión del mismo | ||||
| status | ?!SΣ | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. Required Pattern: final | ||||
| type | SΣ | 1..1 | CodeableConcept | Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (required) | ||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 1..1 | Reference(Patient) | Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | SΣC | 1..1 | string | Corresponde al paciente | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter | SΣ | 0..1 | Reference(Encounter) | Contexto del Documento. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | SΣC | 1..1 | string | Corresponde al paciente | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | SΣ | 0..1 | Identifier | Identificador, en formato identifier para el encuentro | ||||
| display | SΣ | 0..1 | string | texto que describe el contexto del documento | ||||
| date | SΣ | 1..1 | dateTime | Fecha en la cual se editó el documento | ||||
| author | SΣ | 1..1 | Reference(Practitioner) | Quien Ha creado el documento | ||||
| title | SΣ | 1..1 | string | Título del documento generado | ||||
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | S | 0..* | BackboneElement | Validadores del documento | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required) | ||||
| time | S | 0..1 | dateTime | Fecha y Hora de la validación | ||||
| party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Quien validó | ||||
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
 target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(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 | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section | SC | 1..* | BackboneElement | Sección del documento Slice: Unordered, Open by pattern:code | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) | ||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:sectionDiagnosticos | SC | 0..* | BackboneElement | Sección Diagnósticos | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | SC | 1..* | Reference(Condition) | Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:sectionMedicamentos | SC | 0..* | BackboneElement | Sección Medicamentos | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | SC | 1..* | Reference(MedicationStatement) | Referencia al Medicamento Prescrito al paciente. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:sectionAlergias | SC | 0..* | BackboneElement | Sección Alergias y Reacciones Adversas | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | SC | 1..* | Reference(AllergyIntolerance) | Alergias e Intolerancia descrita | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:sectionObservacionEmbarazo | SC | 0..* | BackboneElement | Sección Antecedentes de Embarazo | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | SC | 1..* | Reference(Observation) | Descripción del antecedente de embarzo | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:sectionObservacionSignosVitales | SC | 0..* | BackboneElement | Sección de Signos Vitales Medidos | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | SC | 1..* | Reference(Observation) | Descripción del los signos vitales y mediciones desarrolladas | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | Pattern: final | ||||
| Composition.type | required | VSTiposDocClinic (a valid code from LOINC) | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.subject.type | extensible | ResourceType | ||||
| Composition.encounter.type | extensible | ResourceType | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionDiagnosticos.code | example | Pattern: LOINC code 11450-4 | ||||
| Composition.section:sectionDiagnosticos.mode | required | ListMode | ||||
| Composition.section:sectionDiagnosticos.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionDiagnosticos.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionMedicamentos.code | example | Pattern: LOINC code 10160-0 | ||||
| Composition.section:sectionMedicamentos.mode | required | ListMode | ||||
| Composition.section:sectionMedicamentos.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionMedicamentos.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionAlergias.code | example | Pattern: LOINC code 48765-2 | ||||
| Composition.section:sectionAlergias.mode | required | ListMode | ||||
| Composition.section:sectionAlergias.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionAlergias.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionObservacionEmbarazo.code | example | Pattern: LOINC code 10162-6 | ||||
| Composition.section:sectionObservacionEmbarazo.mode | required | ListMode | ||||
| Composition.section:sectionObservacionEmbarazo.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionObservacionEmbarazo.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionObservacionSignosVitales.code | example | Pattern: LOINC code 8716-3 | ||||
| Composition.section:sectionObservacionSignosVitales.mode | required | ListMode | ||||
| Composition.section:sectionObservacionSignosVitales.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionObservacionSignosVitales.emptyReason | preferred | ListEmptyReasons |
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:
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| identifier | S | 0..1 | Identifier | Identificador local para recurso de documeto que puede ser distinto para cada versión del mismo |
| status | S | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Required Pattern: final |
| type | S | 1..1 | CodeableConcept | Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (required) |
| subject | S | 1..1 | Reference(Patient) | Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno. |
| reference | S | 1..1 | string | Corresponde al paciente |
| encounter | S | 0..1 | Reference(Encounter) | Contexto del Documento. |
| reference | S | 1..1 | string | Corresponde al paciente |
| identifier | S | 0..1 | Identifier | Identificador, en formato identifier para el encuentro |
| display | S | 0..1 | string | texto que describe el contexto del documento |
| date | S | 1..1 | dateTime | Fecha en la cual se editó el documento |
| author | S | 1..1 | Reference(Practitioner) | Quien Ha creado el documento |
| title | S | 1..1 | string | Título del documento generado |
| attester | S | 0..* | BackboneElement | Validadores del documento |
| mode | S | 1..1 | code | Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required) |
| time | S | 0..1 | dateTime | Fecha y Hora de la validación |
| party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Quien validó |
| Slices for section | S | 1..* | BackboneElement | Sección del documento Slice: Unordered, Open by pattern:code |
| section:All Slices | Content/Rules for all slices | |||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| section:sectionDiagnosticos | S | 0..* | BackboneElement | Sección Diagnósticos |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| 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 | 1..* | Reference(Condition) | Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente. Slice: Unordered, Open by profile:resolve() |
| section:sectionMedicamentos | S | 0..* | BackboneElement | Sección Medicamentos |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| 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 | 1..* | Reference(MedicationStatement) | Referencia al Medicamento Prescrito al paciente. Slice: Unordered, Open by profile:resolve() |
| section:sectionAlergias | S | 0..* | BackboneElement | Sección Alergias y Reacciones Adversas |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| 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 | 1..* | Reference(AllergyIntolerance) | Alergias e Intolerancia descrita Slice: Unordered, Open by profile:resolve() |
| section:sectionObservacionEmbarazo | S | 0..* | BackboneElement | Sección Antecedentes de Embarazo |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| 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 | 1..* | Reference(Observation) | Descripción del antecedente de embarzo Slice: Unordered, Open by profile:resolve() |
| section:sectionObservacionSignosVitales | S | 0..* | BackboneElement | Sección de Signos Vitales Medidos |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| 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: 8716-3 | |
| entry | S | 1..* | Reference(Observation) | Descripción del los signos vitales y mediciones desarrolladas Slice: Unordered, Open by profile:resolve() |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Composition.type | required | VSTiposDocClinic (a valid code from LOINC) |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.section.code | example | DocumentSectionCodes |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SΣ | 0..1 | Identifier | Identificador local para recurso de documeto que puede ser distinto para cada versión del mismo |
| status | ?!SΣ | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. Required Pattern: final |
| type | SΣ | 1..1 | CodeableConcept | Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (required) |
| subject | SΣ | 1..1 | Reference(Patient) | Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno. |
| reference | SΣC | 1..1 | string | Corresponde al paciente |
| encounter | SΣ | 0..1 | Reference(Encounter) | Contexto del Documento. |
| reference | SΣC | 1..1 | string | Corresponde al paciente |
| identifier | SΣ | 0..1 | Identifier | Identificador, en formato identifier para el encuentro |
| display | SΣ | 0..1 | string | texto que describe el contexto del documento |
| date | SΣ | 1..1 | dateTime | Fecha en la cual se editó el documento |
| author | SΣ | 1..1 | Reference(Practitioner) | Quien Ha creado el documento |
| title | SΣ | 1..1 | string | Título del documento generado |
| attester | S | 0..* | BackboneElement | Validadores del documento |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | S | 1..1 | code | Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required) |
| time | S | 0..1 | dateTime | Fecha y Hora de la validación |
| party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Quien validó |
| Slices for section | SC | 1..* | BackboneElement | Sección del documento Slice: Unordered, Open by pattern:code |
| section:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) |
| section:sectionDiagnosticos | SC | 0..* | BackboneElement | Sección Diagnósticos |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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 | SC | 1..* | Reference(Condition) | Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente. |
| section:sectionMedicamentos | SC | 0..* | BackboneElement | Sección Medicamentos |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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 | SC | 1..* | Reference(MedicationStatement) | Referencia al Medicamento Prescrito al paciente. |
| section:sectionAlergias | SC | 0..* | BackboneElement | Sección Alergias y Reacciones Adversas |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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 | SC | 1..* | Reference(AllergyIntolerance) | Alergias e Intolerancia descrita |
| section:sectionObservacionEmbarazo | SC | 0..* | BackboneElement | Sección Antecedentes de Embarazo |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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 | SC | 1..* | Reference(Observation) | Descripción del antecedente de embarzo |
| section:sectionObservacionSignosVitales | SC | 0..* | BackboneElement | Sección de Signos Vitales Medidos |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| title | S | 1..1 | string | Label for section (e.g. for ToC) |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. 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: 8716-3 | |
| entry | SC | 1..* | Reference(Observation) | Descripción del los signos vitales y mediciones desarrolladas |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Composition.status | required | Pattern: final |
| Composition.type | required | VSTiposDocClinic (a valid code from LOINC) |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.section.code | example | DocumentSectionCodes |
| Composition.section:sectionDiagnosticos.code | example | Pattern: LOINC code 11450-4 |
| Composition.section:sectionMedicamentos.code | example | Pattern: LOINC code 10160-0 |
| Composition.section:sectionAlergias.code | example | Pattern: LOINC code 48765-2 |
| Composition.section:sectionObservacionEmbarazo.code | example | Pattern: LOINC code 10162-6 |
| Composition.section:sectionObservacionSignosVitales.code | example | Pattern: LOINC code 8716-3 |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣ | 0..1 | Identifier | Identificador local para recurso de documeto que puede ser distinto para cada versión del mismo | ||||
| status | ?!SΣ | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. Required Pattern: final | ||||
| type | SΣ | 1..1 | CodeableConcept | Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (required) | ||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 1..1 | Reference(Patient) | Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | SΣC | 1..1 | string | Corresponde al paciente | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter | SΣ | 0..1 | Reference(Encounter) | Contexto del Documento. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | SΣC | 1..1 | string | Corresponde al paciente | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | SΣ | 0..1 | Identifier | Identificador, en formato identifier para el encuentro | ||||
| display | SΣ | 0..1 | string | texto que describe el contexto del documento | ||||
| date | SΣ | 1..1 | dateTime | Fecha en la cual se editó el documento | ||||
| author | SΣ | 1..1 | Reference(Practitioner) | Quien Ha creado el documento | ||||
| title | SΣ | 1..1 | string | Título del documento generado | ||||
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | S | 0..* | BackboneElement | Validadores del documento | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | S | 1..1 | code | Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required) | ||||
| time | S | 0..1 | dateTime | Fecha y Hora de la validación | ||||
| party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Quien validó | ||||
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(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 | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section | SC | 1..* | BackboneElement | Sección del documento Slice: Unordered, Open by pattern:code | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example) | ||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:sectionDiagnosticos | SC | 0..* | BackboneElement | Sección Diagnósticos | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11450-4 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | SC | 1..* | Reference(Condition) | Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:sectionMedicamentos | SC | 0..* | BackboneElement | Sección Medicamentos | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | SC | 1..* | Reference(MedicationStatement) | Referencia al Medicamento Prescrito al paciente. | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:sectionAlergias | SC | 0..* | BackboneElement | Sección Alergias y Reacciones Adversas | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | SC | 1..* | Reference(AllergyIntolerance) | Alergias e Intolerancia descrita | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:sectionObservacionEmbarazo | SC | 0..* | BackboneElement | Sección Antecedentes de Embarazo | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10162-6 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | SC | 1..* | Reference(Observation) | Descripción del antecedente de embarzo | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:sectionObservacionSignosVitales | SC | 0..* | BackboneElement | Sección de Signos Vitales Medidos | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | SC | 1..* | Reference(Observation) | Descripción del los signos vitales y mediciones desarrolladas | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | Pattern: final | ||||
| Composition.type | required | VSTiposDocClinic (a valid code from LOINC) | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.subject.type | extensible | ResourceType | ||||
| Composition.encounter.type | extensible | ResourceType | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionDiagnosticos.code | example | Pattern: LOINC code 11450-4 | ||||
| Composition.section:sectionDiagnosticos.mode | required | ListMode | ||||
| Composition.section:sectionDiagnosticos.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionDiagnosticos.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionMedicamentos.code | example | Pattern: LOINC code 10160-0 | ||||
| Composition.section:sectionMedicamentos.mode | required | ListMode | ||||
| Composition.section:sectionMedicamentos.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionMedicamentos.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionAlergias.code | example | Pattern: LOINC code 48765-2 | ||||
| Composition.section:sectionAlergias.mode | required | ListMode | ||||
| Composition.section:sectionAlergias.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionAlergias.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionObservacionEmbarazo.code | example | Pattern: LOINC code 10162-6 | ||||
| Composition.section:sectionObservacionEmbarazo.mode | required | ListMode | ||||
| Composition.section:sectionObservacionEmbarazo.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionObservacionEmbarazo.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:sectionObservacionSignosVitales.code | example | Pattern: LOINC code 8716-3 | ||||
| Composition.section:sectionObservacionSignosVitales.mode | required | ListMode | ||||
| Composition.section:sectionObservacionSignosVitales.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:sectionObservacionSignosVitales.emptyReason | preferred | ListEmptyReasons |
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:
Other representations of profile: CSV, Excel, Schematron