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

This page is part of the Chile Core (v1.8.6: STU2 Draft) based on FHIR (HL7® FHIR® Standard) 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: 1.8.6
Active as of 2024-02-15 Computable Name: DocumentoCl

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

De un formato genérico para documento clínico en Chile.

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
Binding: CompositionStatus (required): Códigos requeridos por estándar

... type S1..1CodeableConceptTipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (preferred)
... encounter S0..1Reference(Encuentro Clínico)Contexto asistencial en el cual se generó Documento.
... date S1..1dateTimeFecha en la cual se editó el documento
... author S1..*Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Prestador | CL Organización)Quien Ha creado el documento
... title S1..1stringTítulo del documento generado
... attester S0..*BackboneElementProfesionales validadores del documento
.... mode S1..1codeLabor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR

.... time S0..1dateTimeFecha y Hora de la validación
.... party S0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Quien validó
... custodian S0..1Reference(Organization)Organización que mantiene los documentos
... section S1..*BackboneElementSección del documento
.... code S0..1CodeableConceptCódigo que define el tipo de sección
Binding: DocumentSectionCodes (example)
.... text S0..1NarrativeTexto que describe el contenido de la sección
.... entry S0..*Reference(Resource)Recurso referenciado en esta sección

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status
from the FHIR Standard
Composition.typepreferredVSTiposDocClinic (a valid code from LOINC)
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinic
from this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode
from the FHIR Standard
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
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 (preferred)
... subject SΣ0..1Reference(CL Paciente)Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno.
... encounter SΣ0..1Reference(Encuentro Clínico)Contexto asistencial en el cual se generó Documento.
... date SΣ1..1dateTimeFecha en la cual se editó el documento
... author SΣ1..*Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Prestador | CL Organización)Quien Ha creado el documento
... title SΣ1..1stringTítulo del documento generado
... attester S0..*BackboneElementProfesionales validadores del documento
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode S1..1codeLabor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR

.... time S0..1dateTimeFecha y Hora de la validación
.... party S0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Quien validó
... custodian SΣ0..1Reference(Organization)Organización que mantiene los documentos
... section SC1..*BackboneElementSección del documento
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code S0..1CodeableConceptCódigo que define el tipo de sección
Binding: DocumentSectionCodes (example)
.... text SC0..1NarrativeTexto que describe el contenido de la sección
.... entry SC0..*Reference(Resource)Recurso referenciado en esta sección

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status
from the FHIR Standard
Composition.typepreferredVSTiposDocClinic (a valid code from LOINC)
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinic
from this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode
from the FHIR Standard
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
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): Códigos requeridos por estándar

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


... subject SΣ0..1Reference(CL Paciente)Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno.
... encounter SΣ0..1Reference(Encuentro Clínico)Contexto asistencial en el cual se generó Documento.
... date SΣ1..1dateTimeFecha en la cual se editó el documento
... author SΣ1..*Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Prestador | CL Organización)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..*BackboneElementProfesionales validadores 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): Códigos requeridos por FHIR

.... time S0..1dateTimeFecha y Hora de la validación
.... party S0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Quien validó
... custodian SΣ0..1Reference(Organization)Organización que mantiene los documentos
... 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
... section SC1..*BackboneElementSección 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
.... title 0..1stringLabel for section (e.g. for ToC)
.... code S0..1CodeableConceptCódigo que define el tipo de sección
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 SC0..1NarrativeTexto que describe el contenido de la sección
.... 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 SC0..*Reference(Resource)Recurso referenciado en esta sección
.... 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

PathConformanceValueSetURI
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status
from the FHIR Standard
Composition.typepreferredVSTiposDocClinic (a valid code from LOINC)
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinic
from this IG
Composition.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
Composition.confidentialityrequiredv3.ConfidentialityClassification
http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26
from the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard

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
Binding: CompositionStatus (required): Códigos requeridos por estándar

... type S1..1CodeableConceptTipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5
Binding: Tipos de Documentos Clínicos (preferred)
... encounter S0..1Reference(Encuentro Clínico)Contexto asistencial en el cual se generó Documento.
... date S1..1dateTimeFecha en la cual se editó el documento
... author S1..*Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Prestador | CL Organización)Quien Ha creado el documento
... title S1..1stringTítulo del documento generado
... attester S0..*BackboneElementProfesionales validadores del documento
.... mode S1..1codeLabor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR

.... time S0..1dateTimeFecha y Hora de la validación
.... party S0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Quien validó
... custodian S0..1Reference(Organization)Organización que mantiene los documentos
... section S1..*BackboneElementSección del documento
.... code S0..1CodeableConceptCódigo que define el tipo de sección
Binding: DocumentSectionCodes (example)
.... text S0..1NarrativeTexto que describe el contenido de la sección
.... entry S0..*Reference(Resource)Recurso referenciado en esta sección

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status
from the FHIR Standard
Composition.typepreferredVSTiposDocClinic (a valid code from LOINC)
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinic
from this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode
from the FHIR Standard
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard

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 (preferred)
... subject SΣ0..1Reference(CL Paciente)Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno.
... encounter SΣ0..1Reference(Encuentro Clínico)Contexto asistencial en el cual se generó Documento.
... date SΣ1..1dateTimeFecha en la cual se editó el documento
... author SΣ1..*Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Prestador | CL Organización)Quien Ha creado el documento
... title SΣ1..1stringTítulo del documento generado
... attester S0..*BackboneElementProfesionales validadores del documento
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode S1..1codeLabor del Validador personal|profesional|legal|official
Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR

.... time S0..1dateTimeFecha y Hora de la validación
.... party S0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Quien validó
... custodian SΣ0..1Reference(Organization)Organización que mantiene los documentos
... section SC1..*BackboneElementSección del documento
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code S0..1CodeableConceptCódigo que define el tipo de sección
Binding: DocumentSectionCodes (example)
.... text SC0..1NarrativeTexto que describe el contenido de la sección
.... entry SC0..*Reference(Resource)Recurso referenciado en esta sección

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status
from the FHIR Standard
Composition.typepreferredVSTiposDocClinic (a valid code from LOINC)
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinic
from this IG
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode
from the FHIR Standard
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard

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): Códigos requeridos por estándar

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


... subject SΣ0..1Reference(CL Paciente)Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno.
... encounter SΣ0..1Reference(Encuentro Clínico)Contexto asistencial en el cual se generó Documento.
... date SΣ1..1dateTimeFecha en la cual se editó el documento
... author SΣ1..*Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Prestador | CL Organización)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..*BackboneElementProfesionales validadores 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): Códigos requeridos por FHIR

.... time S0..1dateTimeFecha y Hora de la validación
.... party S0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Quien validó
... custodian SΣ0..1Reference(Organization)Organización que mantiene los documentos
... 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
... section SC1..*BackboneElementSección 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
.... title 0..1stringLabel for section (e.g. for ToC)
.... code S0..1CodeableConceptCódigo que define el tipo de sección
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 SC0..1NarrativeTexto que describe el contenido de la sección
.... 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 SC0..*Reference(Resource)Recurso referenciado en esta sección
.... 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

PathConformanceValueSetURI
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status
from the FHIR Standard
Composition.typepreferredVSTiposDocClinic (a valid code from LOINC)
https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinic
from this IG
Composition.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
Composition.confidentialityrequiredv3.ConfidentialityClassification
http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26
from the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard

 

Other representations of profile: CSV, Excel, Schematron