Guía de Implementación ''cl core'' FHIR R4, (Versión Evolutiva)
1.9.4 - trial-use
This page is part of the Chile Core (v1.9.4: STU4 Draft) based on FHIR (HL7® FHIR® Standard) R4. This version is a pre-release. The current official version is 1.9.3. For a full list of available versions, see the Directory of published versions
| Official URL: https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/DocumentoCl | Version: 1.9.4 | |||
| Active as of 2025-10-02 | 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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De un formato genérico para documento clínico en Chile.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
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0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
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?!Σ | 0..1 | uri | A set of rules under which this content was created |
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?! | 0..* | Extension | Extensions that cannot be ignored |
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SΣ | 0..1 | Identifier | Identificador local para recurso de documento que puede ser distinto para cada versión del mismo |
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?!SΣ | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar |
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SΣ | 1..1 | CodeableConcept | Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (preferred) |
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SΣ | 0..1 | Reference(Resource) | Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno. |
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SΣ | 0..1 | Reference(CL Encuentro Clínico) | Contexto asistencial en el cual se generó Documento. |
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SΣ | 1..1 | dateTime | Fecha en la cual se editó el documento |
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SΣ | 1..* | Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización) | Quien Ha creado el documento |
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SΣ | 1..1 | string | Título del documento generado |
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S | 0..* | BackboneElement | Profesionales validadores del documento |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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S | 1..1 | code | Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR |
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S | 0..1 | dateTime | Fecha y Hora de la validación |
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S | 0..1 | Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización) | Quien validó |
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SΣ | 0..1 | Reference(CL Organización) | Organización que mantiene los documentos |
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SC | 1..* | BackboneElement | Sección del documento Constraints: cmp-1, cmp-2 |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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S | 0..1 | CodeableConcept | Código que define el tipo de sección Binding: DocumentSectionCodes (example) |
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SC | 0..1 | Narrative | Texto que describe el contenido de la sección This profile does not constrain the narrative in regard to content, language, or traceability to data elements |
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SC | 0..* | Reference(Resource) | Recurso referenciado en esta sección |
Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-statusFrom the FHIR Standard | |
| Composition.type | preferred | VSTiposDocClinico(a valid code from LOINC)https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinicoFrom this IG | |
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-modeFrom the FHIR Standard | |
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
![]() ![]() |
S | 0..1 | Identifier | Identificador local para recurso de documento que puede ser distinto para cada versión del mismo |
![]() ![]() |
S | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar |
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S | 1..1 | CodeableConcept | Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (preferred) |
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S | 0..1 | Reference(Resource) | Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno. |
![]() ![]() |
S | 0..1 | Reference(CL Encuentro Clínico) | Contexto asistencial en el cual se generó Documento. |
![]() ![]() |
S | 1..1 | dateTime | Fecha en la cual se editó el documento |
![]() ![]() |
S | 1..* | Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización) | Quien Ha creado el documento |
![]() ![]() |
S | 1..1 | string | Título del documento generado |
![]() ![]() |
S | 0..* | BackboneElement | Profesionales validadores del documento |
![]() ![]() ![]() |
S | 1..1 | code | Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR |
![]() ![]() ![]() |
S | 0..1 | dateTime | Fecha y Hora de la validación |
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S | 0..1 | Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización) | Quien validó |
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S | 0..1 | Reference(CL Organización) | Organización que mantiene los documentos |
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S | 1..* | BackboneElement | Sección del documento |
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S | 0..1 | CodeableConcept | Código que define el tipo de sección Binding: DocumentSectionCodes (example) |
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S | 0..1 | Narrative | Texto que describe el contenido de la sección |
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S | 0..* | Reference(Resource) | Recurso referenciado en esta sección |
Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-statusFrom the FHIR Standard | |
| Composition.type | preferred | VSTiposDocClinico(a valid code from LOINC)https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinicoFrom this IG | |
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-modeFrom the FHIR Standard | |
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesFrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
|---|---|---|---|---|---|---|---|---|
![]() |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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SΣ | 0..1 | Identifier | Identificador local para recurso de documento que puede ser distinto para cada versión del mismo | ||||
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?!SΣ | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar | ||||
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SΣ | 1..1 | CodeableConcept | Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (preferred) | ||||
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Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
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SΣ | 0..1 | Reference(Resource) | Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno. | ||||
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SΣ | 0..1 | Reference(CL Encuentro Clínico) | Contexto asistencial en el cual se generó Documento. | ||||
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SΣ | 1..1 | dateTime | Fecha en la cual se editó el documento | ||||
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SΣ | 1..* | Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización) | Quien Ha creado el documento | ||||
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SΣ | 1..1 | string | Título del documento generado | ||||
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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. | ||||
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S | 0..* | BackboneElement | Profesionales validadores del documento | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | code | Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR | ||||
![]() ![]() ![]() |
S | 0..1 | dateTime | Fecha y Hora de la validación | ||||
![]() ![]() ![]() |
S | 0..1 | Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización) | Quien validó | ||||
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SΣ | 0..1 | Reference(CL Organización) | Organización que mantiene los documentos | ||||
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0..* | BackboneElement | Relationships to other compositions/documents | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
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1..1 | Target of the relationship | ||||||
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Identifier | |||||||
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Reference(Composition) | |||||||
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Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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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. | ||||
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Σ | 0..1 | Period | The period covered by the documentation | ||||
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Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
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SC | 1..* | BackboneElement | Sección del documento Constraints: cmp-1, cmp-2 | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | string | Label for section (e.g. for ToC) | |||||
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S | 0..1 | CodeableConcept | Código que define el tipo de sección Binding: DocumentSectionCodes (example) | ||||
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0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
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0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
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SC | 0..1 | Narrative | Texto que describe el contenido de la sección This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
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0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
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0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
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SC | 0..* | Reference(Resource) | Recurso referenciado en esta sección | ||||
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C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-statusFrom the FHIR Standard | ||||
| Composition.type | preferred | VSTiposDocClinico(a valid code from LOINC)https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinicoFrom this IG | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesFrom the FHIR Standard | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26From the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-modeFrom the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1From the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesFrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1From the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderFrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 1 element
Must-Support: 17 elements
Structures
This structure refers to these other structures:
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() |
SΣ | 0..1 | Identifier | Identificador local para recurso de documento que puede ser distinto para cada versión del mismo |
![]() ![]() |
?!SΣ | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar |
![]() ![]() |
SΣ | 1..1 | CodeableConcept | Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (preferred) |
![]() ![]() |
SΣ | 0..1 | Reference(Resource) | Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno. |
![]() ![]() |
SΣ | 0..1 | Reference(CL Encuentro Clínico) | Contexto asistencial en el cual se generó Documento. |
![]() ![]() |
SΣ | 1..1 | dateTime | Fecha en la cual se editó el documento |
![]() ![]() |
SΣ | 1..* | Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización) | Quien Ha creado el documento |
![]() ![]() |
SΣ | 1..1 | string | Título del documento generado |
![]() ![]() |
S | 0..* | BackboneElement | Profesionales validadores del documento |
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
![]() ![]() ![]() |
S | 1..1 | code | Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR |
![]() ![]() ![]() |
S | 0..1 | dateTime | Fecha y Hora de la validación |
![]() ![]() ![]() |
S | 0..1 | Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización) | Quien validó |
![]() ![]() |
SΣ | 0..1 | Reference(CL Organización) | Organización que mantiene los documentos |
![]() ![]() |
SC | 1..* | BackboneElement | Sección del documento Constraints: cmp-1, cmp-2 |
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
![]() ![]() ![]() |
S | 0..1 | CodeableConcept | Código que define el tipo de sección Binding: DocumentSectionCodes (example) |
![]() ![]() ![]() |
SC | 0..1 | Narrative | Texto que describe el contenido de la sección This profile does not constrain the narrative in regard to content, language, or traceability to data elements |
![]() ![]() ![]() |
SC | 0..* | Reference(Resource) | Recurso referenciado en esta sección |
Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-statusFrom the FHIR Standard | |
| Composition.type | preferred | VSTiposDocClinico(a valid code from LOINC)https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinicoFrom this IG | |
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-modeFrom the FHIR Standard | |
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
![]() ![]() |
S | 0..1 | Identifier | Identificador local para recurso de documento que puede ser distinto para cada versión del mismo |
![]() ![]() |
S | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar |
![]() ![]() |
S | 1..1 | CodeableConcept | Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (preferred) |
![]() ![]() |
S | 0..1 | Reference(Resource) | Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno. |
![]() ![]() |
S | 0..1 | Reference(CL Encuentro Clínico) | Contexto asistencial en el cual se generó Documento. |
![]() ![]() |
S | 1..1 | dateTime | Fecha en la cual se editó el documento |
![]() ![]() |
S | 1..* | Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización) | Quien Ha creado el documento |
![]() ![]() |
S | 1..1 | string | Título del documento generado |
![]() ![]() |
S | 0..* | BackboneElement | Profesionales validadores del documento |
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S | 1..1 | code | Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR |
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S | 0..1 | dateTime | Fecha y Hora de la validación |
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S | 0..1 | Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización) | Quien validó |
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S | 0..1 | Reference(CL Organización) | Organización que mantiene los documentos |
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S | 1..* | BackboneElement | Sección del documento |
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S | 0..1 | CodeableConcept | Código que define el tipo de sección Binding: DocumentSectionCodes (example) |
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S | 0..1 | Narrative | Texto que describe el contenido de la sección |
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S | 0..* | Reference(Resource) | Recurso referenciado en esta sección |
Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-statusFrom the FHIR Standard | |
| Composition.type | preferred | VSTiposDocClinico(a valid code from LOINC)https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinicoFrom this IG | |
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-modeFrom the FHIR Standard | |
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesFrom the FHIR Standard |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
|---|---|---|---|---|---|---|---|---|
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0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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SΣ | 0..1 | Identifier | Identificador local para recurso de documento que puede ser distinto para cada versión del mismo | ||||
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?!SΣ | 1..1 | code | Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar | ||||
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SΣ | 1..1 | CodeableConcept | Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (preferred) | ||||
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Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
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SΣ | 0..1 | Reference(Resource) | Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno. | ||||
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SΣ | 0..1 | Reference(CL Encuentro Clínico) | Contexto asistencial en el cual se generó Documento. | ||||
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SΣ | 1..1 | dateTime | Fecha en la cual se editó el documento | ||||
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SΣ | 1..* | Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización) | Quien Ha creado el documento | ||||
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SΣ | 1..1 | string | Título del documento generado | ||||
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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. | ||||
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S | 0..* | BackboneElement | Profesionales validadores del documento | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | code | Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR | ||||
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S | 0..1 | dateTime | Fecha y Hora de la validación | ||||
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S | 0..1 | Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización) | Quien validó | ||||
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SΣ | 0..1 | Reference(CL Organización) | Organización que mantiene los documentos | ||||
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0..* | BackboneElement | Relationships to other compositions/documents | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
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1..1 | Target of the relationship | ||||||
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Identifier | |||||||
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Reference(Composition) | |||||||
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Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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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. | ||||
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Σ | 0..1 | Period | The period covered by the documentation | ||||
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Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
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SC | 1..* | BackboneElement | Sección del documento Constraints: cmp-1, cmp-2 | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | string | Label for section (e.g. for ToC) | |||||
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S | 0..1 | CodeableConcept | Código que define el tipo de sección Binding: DocumentSectionCodes (example) | ||||
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0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
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0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
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SC | 0..1 | Narrative | Texto que describe el contenido de la sección This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
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0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
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0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
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SC | 0..* | Reference(Resource) | Recurso referenciado en esta sección | ||||
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C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-statusFrom the FHIR Standard | ||||
| Composition.type | preferred | VSTiposDocClinico(a valid code from LOINC)https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinicoFrom this IG | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesFrom the FHIR Standard | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26From the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-modeFrom the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1From the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesFrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1From the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderFrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 1 element
Must-Support: 17 elements
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron