Austrian Patient Summary (R4)
1.0.0 - STU1

Austrian Patient Summary (R4) - Downloaded Version 1.0.0 See the Directory of published versions

## Resource Profile: AtApsComposition - Detailed Descriptions

Active as of 2026-02-17

Definitions for the at-aps-composition resource profile.

- Key Elements Table
- Differential Elements Table
- Snapshot Elements Table

Guidance on how to interpret the contents of this table can be foundhere

0. Composition
Definition | A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).
Short | AT APS CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
Comments | While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
Control | 0..*
Is Modifier | false
Impose Profile | This profile also requires that the instance also conform this additional profile: Composition (IPS)
Summary | false
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) aps-comp-1: For automatically generated APS an attester is not allowed (`(author.resolve().ofType(Device).count() != author.count() or attester.count() = 0)`)
2. Composition.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Short | A set of rules under which this content was created
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Control | 0..1
Type | uri
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. Composition.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. Composition.status
Definition | The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.
Short | preliminary | final | amended | entered-in-error
Comments | If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.
Control | 1..1
Binding | The codes SHALL be taken from CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 (required to `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` ) The workflow/clinical status of the composition.
Type | code
Is Modifier | true because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to be able to mark interim, amended, or withdrawn compositions or documents.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Composition.type
Definition | Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition.
Short | Kind of composition (LOINC if possible)
Comments | For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.
Control | 1..1
Binding | The codes SHOULD be taken from FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes|4.0.1 (preferred to `http://hl7.org/fhir/ValueSet/doc-typecodes|4.0.1` ) Type of a composition.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Key metadata element describing the composition, used in searching/filtering.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Composition.subject
Definition | Patientendaten, inkl. Angabe von Kontaktpersonen, Hausarzt bzw. primäre Ansprechpartner. Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).
Short | The person the Austrian Patient Summary is about.Who and/or what the composition is about
Comments | For clinical documents, this is usually the patient.
Control | 0..1
Type | Reference(AT APS Patient, Resource)
Is Modifier | false
Summary | true
Requirements | Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Composition.date
Definition | The composition editing time, when the composition was last logically changed by the author.
Short | Composition editing time
Comments | The Last Modified Date on the composition may be after the date of the document was attested without being changed.
Control | 1..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. Composition.author
Definition | Autor der Austrian Patient Summary. Ggf. Angabe eines Devices z.B. bei automatischer Erstellung der Patient Summary durch die zentrale Anwendung. Identifies who is responsible for the information in the composition, not necessarily who typed it in.
Short | Autor der Austrian Patient SummaryWho and/or what authored the composition
Control | 1..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization, Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifier | false
Summary | true
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. Composition.title
Definition | Official human-readable label for the composition.
Short | Human Readable name/title
Comments | For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. Composition.attester
Definition | Person, die die Richtigkeit der Zusammenstellung bestätigt. Darf bei automatischer Erstellung durch ein Device nicht angegeben werden. A participant who has attested to the accuracy of the composition/document.
Short | Person, die die Richtigkeit der Zusammenstellung bestätigt.Attests to accuracy of composition
Comments | Only list each attester once.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Identifies responsibility for the accuracy of the composition content.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. Composition.attester.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
22. Composition.attester.mode
Definition | The type of attestation the authenticator offers.
Short | personal | professional | legal | official
Control | 1..1
Binding | The codes SHALL be taken from CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 (required to `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` ) The way in which a person authenticated a composition.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Indicates the level of authority of the attestation.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. Composition.attester.party
Definition | Who attested the composition in the specified way.
Short | Who attested the composition
Control | 0..1
Type | Reference(AT APS Patient, RelatedPerson, AT APS Practitioner, AT APS PractitionerRole, AT APS Organization, Patient, RelatedPerson, Practitioner, PractitionerRole, Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who has taken on the responsibility for accuracy of the composition content.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. Composition.custodian
Definition | Organisation, die die Patient Summary verwaltet (z.B. zentrale Anwendung). Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.
Short | Organisation, die die Patient Summary verwaltet (z.b. zentrale Anwendung).Organization which maintains the composition
Comments | This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.
Control | 10..1
Type | Reference(AT APS Organization, Organization)
Is Modifier | false
Summary | true
Requirements | Identifies where to go to find the current version, where to report issues, etc.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. Composition.section
Definition | The root of the sections that make up the composition.
Short | Composition is broken into sections
Control | 50..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
Slicing | This element introduces a set of slices on `Composition.section`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ code
30. Composition.section.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
32. Composition.section.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization, Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. Composition.section:sectionProblems
Slice Name | sectionProblems
Definition | Diese Sektion listet und beschreibt klinische Probleme oder Erkrankungen (kodierte Diagnosen), die derzeit für den Patienten relevant sind bzw. liefert Information über das Nichtvorhandensein. The root of the sections that make up the composition.
Short | Gesundheitsprobleme und Risiken (Problems)Composition is broken into sections
Control | 10..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
36. Composition.section:sectionProblems.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
38. Composition.section:sectionProblems.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "11450-4" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. Composition.section:sectionProblems.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Condition, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
42. Composition.section:sectionProblems.entry:problem
Slice Name | problem
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Condition, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. Composition.section:sectionProblems.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. Composition.section:sectionAllergies
Slice Name | sectionAllergies
Definition | In dieser Sektion werden die relevanten Allergien oder Unverträglichkeiten des Patienten dokumentiert, wobei die Art der Reaktion (z.B. Ausschlag, Anaphylaxie usw.), vorzugsweise die auslösenden Stoffe, sowie optional die Kritikalität und die Bestimmtheit der Allergie beschrieben werden. Zumindest sollten die derzeit aktiven und alle relevanten früheren Allergien und Nebenwirkungen aufgeführt werden. Liegen keine Informationen über Allergien vor oder sind keine Allergien bekannt, sollte dies ebenfalls dokumentiert werden. The root of the sections that make up the composition.
Short | Allergien und Intoleranzen (Allergies and Intolerances)Composition is broken into sections
Control | 10..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
48. Composition.section:sectionAllergies.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
50. Composition.section:sectionAllergies.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "48765-2" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. Composition.section:sectionAllergies.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS AllergyIntolerance, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
54. Composition.section:sectionAllergies.entry:allergyOrIntolerance
Slice Name | allergyOrIntolerance
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS AllergyIntolerance, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. Composition.section:sectionAllergies.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. Composition.section:sectionMedications
Slice Name | sectionMedications
Definition | Diese Sektion enthält eine Beschreibung der aktuell relevanten Medikamente des Patienten bzw. liefert Information über das Nichtvorhandensein. Dabei werden nur rezeptpflichtige Medikamente und wechselwirkungsrelevante OTCs berücksichtigt. The root of the sections that make up the composition.
Short | Medikationsliste (Medication Summary)Composition is broken into sections
Control | 10..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
60. Composition.section:sectionMedications.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
62. Composition.section:sectionMedications.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "10160-0" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
64. Composition.section:sectionMedications.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS MedicationStatement, AT APS MedicationRequest, AT APS MedicationAdministration, AT APS MedicationDispense, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
66. Composition.section:sectionMedications.entry:medicationStatement
Slice Name | medicationStatement
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS MedicationStatement, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
68. Composition.section:sectionMedications.entry:medicationRequest
Slice Name | medicationRequest
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS MedicationRequest, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. Composition.section:sectionMedications.entry:medicationAdministration
Slice Name | medicationAdministration
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS MedicationAdministration, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
72. Composition.section:sectionMedications.entry:medicationDispense
Slice Name | medicationDispense
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS MedicationDispense, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. Composition.section:sectionMedications.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. Composition.section:sectionProceduresHx
Slice Name | sectionProceduresHx
Definition | Diese Sektion enthält eine Beschreibung früherer Eingriffe und Therapien. Darunter fallen zum Beispiel invasive diagnostische Verfahren (z.B. Herzkatheteruntersuchung), therapeutische Verfahren (z.B. Dialyse) und chirurgische Eingriffe (z.B. Appendektomie). Befunde und Dokumentation von z.B. im Rahmen von Disease-Management-Programmen durchgeführten Schulungen und Beratungen werden ebenfalls in dieser Sektion aufgenommen. Die Dokumentation der Information kann am Beispiel der Integrierten Versorgung z.B. der Fallkoordinator übernehmen. The root of the sections that make up the composition.
Short | Eingriffe und Therapien (History of Procedures)Composition is broken into sections
Control | 10..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ips-comp-1: Either section.entry or emptyReason are present (`(entry.reference.exists() or emptyReason.exists())`) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
78. Composition.section:sectionProceduresHx.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
80. Composition.section:sectionProceduresHx.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "47519-4" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
82. Composition.section:sectionProceduresHx.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Procedure, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
84. Composition.section:sectionProceduresHx.entry:procedure
Slice Name | procedure
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Procedure, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
86. Composition.section:sectionProceduresHx.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
88. Composition.section:sectionMedicalDevices
Slice Name | sectionMedicalDevices
Definition | Diese Sektion enthält Informationen und kodierte Einträge, die den Gebrauch von Medizinprodukten in der Krankengeschichte beschreiben, z.B. Insulinpumpen oder Herzschrittmacher. The root of the sections that make up the composition.
Short | Implantate, medizinische Geräte (Medical Devices)Composition is broken into sections
Control | 10..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ips-comp-1: Either section.entry or emptyReason are present (`(entry.reference.exists() or emptyReason.exists())`) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
90. Composition.section:sectionMedicalDevices.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
92. Composition.section:sectionMedicalDevices.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "46264-8" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
94. Composition.section:sectionMedicalDevices.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DeviceUseStatement, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
96. Composition.section:sectionMedicalDevices.entry:deviceStatement
Slice Name | deviceStatement
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DeviceUseStatement, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
98. Composition.section:sectionMedicalDevices.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
100. Composition.section:sectionImmunizations
Slice Name | sectionImmunizations
Definition | Die Sektion beschreibt den aktuellen Impfstatus des Patienten und die dazugehörige Impfhistorie. The root of the sections that make up the composition.
Short | Impfungen (Immunizations)Composition is broken into sections
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
102. Composition.section:sectionImmunizations.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
104. Composition.section:sectionImmunizations.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "11369-6" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
106. Composition.section:sectionImmunizations.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Immunization, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
108. Composition.section:sectionImmunizations.entry:immunization
Slice Name | immunization
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Immunization, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
110. Composition.section:sectionImmunizations.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
112. Composition.section:sectionResults
Slice Name | sectionResults
Definition | Die Sektion fasst Untersuchungsergebnisse zusammen, die am Patienten erhoben oder anhand von biologischen In-vitro-Proben erstellt wurden. Dabei kann es sich um Laborergebnisse, Ergebnisse der anatomischen Pathologie oder um radiologische Ergebnisse handeln. The root of the sections that make up the composition.
Short | Diagnostische Resultate (Results)Composition is broken into sections
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
114. Composition.section:sectionResults.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
116. Composition.section:sectionResults.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "30954-2" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
118. Composition.section:sectionResults.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation, AT APS DiagnosticReport, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: type @ resolve() profile @ resolve()
120. Composition.section:sectionResults.entry:resultsObservationLaboratoryPathology
Slice Name | resultsObservationLaboratoryPathology
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Results Laboratory Pathology, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
122. Composition.section:sectionResults.entry:resultsObservationRadiology
Slice Name | resultsObservationRadiology
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Results Radiology, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
124. Composition.section:sectionResults.entry:resultsDiagnosticReport
Slice Name | resultsDiagnosticReport
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DiagnosticReport, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
126. Composition.section:sectionResults.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
128. Composition.section:sectionAdvanceDirectives
Slice Name | sectionAdvanceDirectives
Definition | Die Sektion kann aktuelle Verfügungen von Patienten beinhalten. The root of the sections that make up the composition.
Short | Willenserklärungen und andere juridische Dokumente (Advance Directives)Composition is broken into sections
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
130. Composition.section:sectionAdvanceDirectives.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
132. Composition.section:sectionAdvanceDirectives.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "42348-3" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
134. Composition.section:sectionAdvanceDirectives.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Consent, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
136. Composition.section:sectionAdvanceDirectives.entry:advanceDirectivesConsent
Slice Name | advanceDirectivesConsent
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Consent, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
138. Composition.section:sectionAdvanceDirectives.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
140. Composition.section:sectionAlerts
Slice Name | sectionAlerts
Definition | Die Sektion ermöglicht Warnmeldungen, wenn bestimmte Umstände eintreten (z.B. wenn Grenzwerte für Blutdruck, Gewicht oder subjektives Befinden einen gewissen Zeitraum überschritten werden). The root of the sections that make up the composition.
Short | Warnungen (Alerts)Composition is broken into sections
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
142. Composition.section:sectionAlerts.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
144. Composition.section:sectionAlerts.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "104605-1" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
146. Composition.section:sectionAlerts.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Flag Alert, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
148. Composition.section:sectionAlerts.entry:alertsFlag
Slice Name | alertsFlag
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Flag Alert, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
150. Composition.section:sectionAlerts.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
152. Composition.section:sectionFunctionalStatus
Slice Name | sectionFunctionalStatus
Definition | Diese Sektion enthält eine Beschreibung der Mobilität bzw. Fähigkeit der Patientin oder des Patienten, Handlungen des täglichen Lebens auszuführen, einschließlich möglicher Bedürfnisse. Hier könnte auch die Pflegestufe dokumentiert werden. The root of the sections that make up the composition.
Short | Beeinträchtigungen (Functional Status)Composition is broken into sections
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
154. Composition.section:sectionFunctionalStatus.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
156. Composition.section:sectionFunctionalStatus.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "47420-5" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
158. Composition.section:sectionFunctionalStatus.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Condition, AT APS ClinicalImpression, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
160. Composition.section:sectionFunctionalStatus.entry:disability
Slice Name | disability
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Condition, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
162. Composition.section:sectionFunctionalStatus.entry:functionalAssessment
Slice Name | functionalAssessment
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS ClinicalImpression, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
164. Composition.section:sectionFunctionalStatus.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
166. Composition.section:sectionPastIllnessHx
Slice Name | sectionPastIllnessHx
Definition | Die Sektion enthält eine Beschreibung der historischen klinischen Probleme oder Erkrankungen, die für die Patientin oder den Patienten in der Vergangenheit diagnostiziert wurden. The root of the sections that make up the composition.
Short | Vergangene Gesundheitsprobleme und Risiken (History of Past Problems)Composition is broken into sections
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
168. Composition.section:sectionPastIllnessHx.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
170. Composition.section:sectionPastIllnessHx.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "11348-0" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
172. Composition.section:sectionPastIllnessHx.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Condition, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
174. Composition.section:sectionPastIllnessHx.entry:pastProblem
Slice Name | pastProblem
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Condition, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
176. Composition.section:sectionPastIllnessHx.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
178. Composition.section:sectionPregnancyHx
Slice Name | sectionPregnancyHx
Definition | Die Sektion ermöglicht die Dokumentation eines Schwangerschaftsstatus inkl. geplantem Entbindungstermin und eine kurze Zusammenfassung von vergangenen Schwangerschaften. The root of the sections that make up the composition.
Short | Schwangerschaftshistorie (History of Pregnancy)Composition is broken into sections
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
180. Composition.section:sectionPregnancyHx.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
182. Composition.section:sectionPregnancyHx.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "10162-6" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
184. Composition.section:sectionPregnancyHx.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Pregnancy Status, AT APS Observation Pregnancy Outcome, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
186. Composition.section:sectionPregnancyHx.entry:pregnancyStatus
Slice Name | pregnancyStatus
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Pregnancy Status, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
188. Composition.section:sectionPregnancyHx.entry:pregnancyOutcomeSummary
Slice Name | pregnancyOutcomeSummary
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Pregnancy Outcome, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
190. Composition.section:sectionPregnancyHx.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
192. Composition.section:sectionPatientStory
Slice Name | sectionPatientStory
Definition | Die Sektion enthält narrativen Text sowie optionale Ressourcen, die zum Ausdruck bringen, was für den Patienten wichtig ist. Dazu können Bedürfnisse, Stärken, Werte, Bedenken und Präferenzen gehören, die für Personen relevant sind, die Unterstützung und Pflege anbieten. The root of the sections that make up the composition.
Short | Patientenbericht (Patient Story)Composition is broken into sections
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
194. Composition.section:sectionPatientStory.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
196. Composition.section:sectionPatientStory.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "81338-6" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
198. Composition.section:sectionPlanOfCare
Slice Name | sectionPlanOfCare
Definition | Die Sektion enthält den Behandlungsplan inkl. Vorschlägen, Zielen und Anordnungen zur Kontrolle oder Verbesserung des Zustands des Patienten, zur Planung der nächsten empfohlenen oder vereinbarten Untersuchungen, Kontrolltermine und Schulungen. Durchgeführte Maßnahmen wie Untersuchungen oder Schulungen können in der Sektion "History of Procedures" dokumentiert werden. The root of the sections that make up the composition.
Short | Behandlungsplan (Plan of Care)Composition is broken into sections
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
200. Composition.section:sectionPlanOfCare.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
202. Composition.section:sectionPlanOfCare.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "18776-5" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
204. Composition.section:sectionPlanOfCare.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS CarePlan, AT APS Immunization, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
206. Composition.section:sectionPlanOfCare.entry:carePlan
Slice Name | carePlan
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS CarePlan, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
208. Composition.section:sectionPlanOfCare.entry:immunizationRecommendation
Slice Name | immunizationRecommendation
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Immunization, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
210. Composition.section:sectionPlanOfCare.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
212. Composition.section:sectionSocialHistory
Slice Name | sectionSocialHistory
Definition | Diese Sektion erfasst den aktuellen Lebensstil einer Person. Angaben zum Rauchverhalten sowie zum Alkoholkonsum werden in den hierfür vorgesehenen spezifischen Ressourcen abgebildet. Weitere relevante Aspekte, wie z.B. körperliche Aktivität, Ernährungsgewohnheiten oder sonstige Verhaltensweisen, werden mithilfe der AtApsObservation-Ressource dokumentiert. The root of the sections that make up the composition.
Short | Lebensstil / Soziale Umstände und Verhalten (Social History)Composition is broken into sections
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
214. Composition.section:sectionSocialHistory.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
216. Composition.section:sectionSocialHistory.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "29762-2" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
218. Composition.section:sectionSocialHistory.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
220. Composition.section:sectionSocialHistory.entry:smokingTobaccoUse
Slice Name | smokingTobaccoUse
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..1* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Tobacco Use, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
222. Composition.section:sectionSocialHistory.entry:alcoholUse
Slice Name | alcoholUse
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..1* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Alcohol Use, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
224. Composition.section:sectionSocialHistory.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
226. Composition.section:sectionVitalSigns
Slice Name | sectionVitalSigns
Definition | Die Sektion umfasst Informationen wie Blutdruck, Körpertemperatur, Herzfrequenz, Atemfrequenz, Größe, Gewicht, Body-Mass-Index, Kopfumfang oder Pulsoximetrie. Insbesondere können auffällige Vitalparameter oder körperliche Befunde wie der letzte, maximale und/oder minimale Wert, der Ausgangswert oder relevante Trends angegeben werden. The root of the sections that make up the composition.
Short | Vitalparameter (Vital Signs)Composition is broken into sections
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
228. Composition.section:sectionVitalSigns.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
230. Composition.section:sectionVitalSigns.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 10..1
Binding | For example codes, see DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1 (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "8716-3" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
232. Composition.section:sectionVitalSigns.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation, AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
234. Composition.section:sectionVitalSigns.entry:vitalSign
Slice Name | vitalSign
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Vital Signs, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
236. Composition.section:sectionVitalSigns.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference, Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be foundhere

0. Composition
Short | AT APS Composition
Impose Profile | This profile also requires that the instance also conform this additional profile: Composition (IPS)
Invariants | aps-comp-1: For automatically generated APS an attester is not allowed (`(author.resolve().ofType(Device).count() != author.count() or attester.count() = 0)`)
2. Composition.subject
Definition | Patientendaten, inkl. Angabe von Kontaktpersonen, Hausarzt bzw. primäre Ansprechpartner.
Short | The person the Austrian Patient Summary is about.
Type | Reference(AT APS Patient)
4. Composition.author
Definition | Autor der Austrian Patient Summary. Ggf. Angabe eines Devices z.B. bei automatischer Erstellung der Patient Summary durch die zentrale Anwendung.
Short | Autor der Austrian Patient Summary
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
6. Composition.attester
Definition | Person, die die Richtigkeit der Zusammenstellung bestätigt. Darf bei automatischer Erstellung durch ein Device nicht angegeben werden.
Short | Person, die die Richtigkeit der Zusammenstellung bestätigt.
8. Composition.attester.party
Type | Reference(AT APS Patient, RelatedPerson, AT APS Practitioner, AT APS PractitionerRole, AT APS Organization)
10. Composition.custodian
Definition | Organisation, die die Patient Summary verwaltet (z.B. zentrale Anwendung).
Short | Organisation, die die Patient Summary verwaltet (z.b. zentrale Anwendung).
Control | 1..?
Type | Reference(AT APS Organization)
12. Composition.relatesTo
14. Composition.relatesTo.target[x]
Type | Choice of: Identifier, Reference(AT APS Composition)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
16. Composition.section
Control | 5..?
Slicing | This element introduces a set of slices on `Composition.section`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ code
18. Composition.section.author
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
20. Composition.section:sectionProblems
Slice Name | sectionProblems
Definition | Diese Sektion listet und beschreibt klinische Probleme oder Erkrankungen (kodierte Diagnosen), die derzeit für den Patienten relevant sind bzw. liefert Information über das Nichtvorhandensein.
Short | Gesundheitsprobleme und Risiken (Problems)
Control | 1..1
22. Composition.section:sectionProblems.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "11450-4" }] }`
24. Composition.section:sectionProblems.entry
Type | Reference(AT APS Condition, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
26. Composition.section:sectionProblems.entry:problem
Slice Name | problem
Control | 0..*
Type | Reference(AT APS Condition)
28. Composition.section:sectionProblems.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
30. Composition.section:sectionAllergies
Slice Name | sectionAllergies
Definition | In dieser Sektion werden die relevanten Allergien oder Unverträglichkeiten des Patienten dokumentiert, wobei die Art der Reaktion (z.B. Ausschlag, Anaphylaxie usw.), vorzugsweise die auslösenden Stoffe, sowie optional die Kritikalität und die Bestimmtheit der Allergie beschrieben werden. Zumindest sollten die derzeit aktiven und alle relevanten früheren Allergien und Nebenwirkungen aufgeführt werden. Liegen keine Informationen über Allergien vor oder sind keine Allergien bekannt, sollte dies ebenfalls dokumentiert werden.
Short | Allergien und Intoleranzen (Allergies and Intolerances)
Control | 1..1
32. Composition.section:sectionAllergies.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "48765-2" }] }`
34. Composition.section:sectionAllergies.entry
Type | Reference(AT APS AllergyIntolerance, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
36. Composition.section:sectionAllergies.entry:allergyOrIntolerance
Slice Name | allergyOrIntolerance
Control | 0..*
Type | Reference(AT APS AllergyIntolerance)
38. Composition.section:sectionAllergies.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
40. Composition.section:sectionMedications
Slice Name | sectionMedications
Definition | Diese Sektion enthält eine Beschreibung der aktuell relevanten Medikamente des Patienten bzw. liefert Information über das Nichtvorhandensein. Dabei werden nur rezeptpflichtige Medikamente und wechselwirkungsrelevante OTCs berücksichtigt.
Short | Medikationsliste (Medication Summary)
Control | 1..1
42. Composition.section:sectionMedications.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "10160-0" }] }`
44. Composition.section:sectionMedications.entry
Type | Reference(AT APS MedicationStatement, AT APS MedicationRequest, AT APS MedicationAdministration, AT APS MedicationDispense, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
46. Composition.section:sectionMedications.entry:medicationStatement
Slice Name | medicationStatement
Control | 0..*
Type | Reference(AT APS MedicationStatement)
48. Composition.section:sectionMedications.entry:medicationRequest
Slice Name | medicationRequest
Control | 0..*
Type | Reference(AT APS MedicationRequest)
50. Composition.section:sectionMedications.entry:medicationAdministration
Slice Name | medicationAdministration
Control | 0..*
Type | Reference(AT APS MedicationAdministration)
52. Composition.section:sectionMedications.entry:medicationDispense
Slice Name | medicationDispense
Control | 0..*
Type | Reference(AT APS MedicationDispense)
54. Composition.section:sectionMedications.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
56. Composition.section:sectionProceduresHx
Slice Name | sectionProceduresHx
Definition | Diese Sektion enthält eine Beschreibung früherer Eingriffe und Therapien. Darunter fallen zum Beispiel invasive diagnostische Verfahren (z.B. Herzkatheteruntersuchung), therapeutische Verfahren (z.B. Dialyse) und chirurgische Eingriffe (z.B. Appendektomie). Befunde und Dokumentation von z.B. im Rahmen von Disease-Management-Programmen durchgeführten Schulungen und Beratungen werden ebenfalls in dieser Sektion aufgenommen. Die Dokumentation der Information kann am Beispiel der Integrierten Versorgung z.B. der Fallkoordinator übernehmen.
Short | Eingriffe und Therapien (History of Procedures)
Control | 1..1
Invariants | ips-comp-1: Either section.entry or emptyReason are present (`(entry.reference.exists() or emptyReason.exists())`)
58. Composition.section:sectionProceduresHx.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "47519-4" }] }`
60. Composition.section:sectionProceduresHx.entry
Type | Reference(AT APS Procedure, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
62. Composition.section:sectionProceduresHx.entry:procedure
Slice Name | procedure
Control | 0..*
Type | Reference(AT APS Procedure)
64. Composition.section:sectionProceduresHx.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
66. Composition.section:sectionMedicalDevices
Slice Name | sectionMedicalDevices
Definition | Diese Sektion enthält Informationen und kodierte Einträge, die den Gebrauch von Medizinprodukten in der Krankengeschichte beschreiben, z.B. Insulinpumpen oder Herzschrittmacher.
Short | Implantate, medizinische Geräte (Medical Devices)
Control | 1..1
Invariants | ips-comp-1: Either section.entry or emptyReason are present (`(entry.reference.exists() or emptyReason.exists())`)
68. Composition.section:sectionMedicalDevices.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "46264-8" }] }`
70. Composition.section:sectionMedicalDevices.entry
Type | Reference(AT APS DeviceUseStatement, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
72. Composition.section:sectionMedicalDevices.entry:deviceStatement
Slice Name | deviceStatement
Control | 0..*
Type | Reference(AT APS DeviceUseStatement)
74. Composition.section:sectionMedicalDevices.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
76. Composition.section:sectionImmunizations
Slice Name | sectionImmunizations
Definition | Die Sektion beschreibt den aktuellen Impfstatus des Patienten und die dazugehörige Impfhistorie.
Short | Impfungen (Immunizations)
Control | 0..1
78. Composition.section:sectionImmunizations.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "11369-6" }] }`
80. Composition.section:sectionImmunizations.entry
Type | Reference(AT APS Immunization, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
82. Composition.section:sectionImmunizations.entry:immunization
Slice Name | immunization
Control | 0..*
Type | Reference(AT APS Immunization)
84. Composition.section:sectionImmunizations.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
86. Composition.section:sectionResults
Slice Name | sectionResults
Definition | Die Sektion fasst Untersuchungsergebnisse zusammen, die am Patienten erhoben oder anhand von biologischen In-vitro-Proben erstellt wurden. Dabei kann es sich um Laborergebnisse, Ergebnisse der anatomischen Pathologie oder um radiologische Ergebnisse handeln.
Short | Diagnostische Resultate (Results)
Control | 0..1
88. Composition.section:sectionResults.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "30954-2" }] }`
90. Composition.section:sectionResults.entry
Type | Reference(AT APS Observation, AT APS DiagnosticReport, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: type @ resolve() profile @ resolve()
92. Composition.section:sectionResults.entry:resultsObservationLaboratoryPathology
Slice Name | resultsObservationLaboratoryPathology
Control | 0..*
Type | Reference(AT APS Observation Results Laboratory Pathology)
94. Composition.section:sectionResults.entry:resultsObservationRadiology
Slice Name | resultsObservationRadiology
Control | 0..*
Type | Reference(AT APS Observation Results Radiology)
96. Composition.section:sectionResults.entry:resultsDiagnosticReport
Slice Name | resultsDiagnosticReport
Control | 0..*
Type | Reference(AT APS DiagnosticReport)
98. Composition.section:sectionResults.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
100. Composition.section:sectionAdvanceDirectives
Slice Name | sectionAdvanceDirectives
Definition | Die Sektion kann aktuelle Verfügungen von Patienten beinhalten.
Short | Willenserklärungen und andere juridische Dokumente (Advance Directives)
Control | 0..1
102. Composition.section:sectionAdvanceDirectives.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "42348-3" }] }`
104. Composition.section:sectionAdvanceDirectives.entry
Type | Reference(AT APS Consent, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
106. Composition.section:sectionAdvanceDirectives.entry:advanceDirectivesConsent
Slice Name | advanceDirectivesConsent
Control | 0..*
Type | Reference(AT APS Consent)
108. Composition.section:sectionAdvanceDirectives.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
110. Composition.section:sectionAlerts
Slice Name | sectionAlerts
Definition | Die Sektion ermöglicht Warnmeldungen, wenn bestimmte Umstände eintreten (z.B. wenn Grenzwerte für Blutdruck, Gewicht oder subjektives Befinden einen gewissen Zeitraum überschritten werden).
Short | Warnungen (Alerts)
Control | 0..1
112. Composition.section:sectionAlerts.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "104605-1" }] }`
114. Composition.section:sectionAlerts.entry
Type | Reference(AT APS Flag Alert, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
116. Composition.section:sectionAlerts.entry:alertsFlag
Slice Name | alertsFlag
Control | 0..*
Type | Reference(AT APS Flag Alert)
118. Composition.section:sectionAlerts.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
120. Composition.section:sectionFunctionalStatus
Slice Name | sectionFunctionalStatus
Definition | Diese Sektion enthält eine Beschreibung der Mobilität bzw. Fähigkeit der Patientin oder des Patienten, Handlungen des täglichen Lebens auszuführen, einschließlich möglicher Bedürfnisse. Hier könnte auch die Pflegestufe dokumentiert werden.
Short | Beeinträchtigungen (Functional Status)
Control | 0..1
122. Composition.section:sectionFunctionalStatus.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "47420-5" }] }`
124. Composition.section:sectionFunctionalStatus.entry
Type | Reference(AT APS Condition, AT APS ClinicalImpression, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
126. Composition.section:sectionFunctionalStatus.entry:disability
Slice Name | disability
Control | 0..*
Type | Reference(AT APS Condition)
128. Composition.section:sectionFunctionalStatus.entry:functionalAssessment
Slice Name | functionalAssessment
Control | 0..*
Type | Reference(AT APS ClinicalImpression)
130. Composition.section:sectionFunctionalStatus.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
132. Composition.section:sectionPastIllnessHx
Slice Name | sectionPastIllnessHx
Definition | Die Sektion enthält eine Beschreibung der historischen klinischen Probleme oder Erkrankungen, die für die Patientin oder den Patienten in der Vergangenheit diagnostiziert wurden.
Short | Vergangene Gesundheitsprobleme und Risiken (History of Past Problems)
Control | 0..1
134. Composition.section:sectionPastIllnessHx.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "11348-0" }] }`
136. Composition.section:sectionPastIllnessHx.entry
Type | Reference(AT APS Condition, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
138. Composition.section:sectionPastIllnessHx.entry:pastProblem
Slice Name | pastProblem
Control | 0..*
Type | Reference(AT APS Condition)
140. Composition.section:sectionPastIllnessHx.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
142. Composition.section:sectionPregnancyHx
Slice Name | sectionPregnancyHx
Definition | Die Sektion ermöglicht die Dokumentation eines Schwangerschaftsstatus inkl. geplantem Entbindungstermin und eine kurze Zusammenfassung von vergangenen Schwangerschaften.
Short | Schwangerschaftshistorie (History of Pregnancy)
Control | 0..1
144. Composition.section:sectionPregnancyHx.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "10162-6" }] }`
146. Composition.section:sectionPregnancyHx.entry
Type | Reference(AT APS Observation Pregnancy Status, AT APS Observation Pregnancy Outcome, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
148. Composition.section:sectionPregnancyHx.entry:pregnancyStatus
Slice Name | pregnancyStatus
Control | 0..*
Type | Reference(AT APS Observation Pregnancy Status)
150. Composition.section:sectionPregnancyHx.entry:pregnancyOutcomeSummary
Slice Name | pregnancyOutcomeSummary
Control | 0..*
Type | Reference(AT APS Observation Pregnancy Outcome)
152. Composition.section:sectionPregnancyHx.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
154. Composition.section:sectionPatientStory
Slice Name | sectionPatientStory
Definition | Die Sektion enthält narrativen Text sowie optionale Ressourcen, die zum Ausdruck bringen, was für den Patienten wichtig ist. Dazu können Bedürfnisse, Stärken, Werte, Bedenken und Präferenzen gehören, die für Personen relevant sind, die Unterstützung und Pflege anbieten.
Short | Patientenbericht (Patient Story)
Control | 0..1
156. Composition.section:sectionPatientStory.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "81338-6" }] }`
158. Composition.section:sectionPlanOfCare
Slice Name | sectionPlanOfCare
Definition | Die Sektion enthält den Behandlungsplan inkl. Vorschlägen, Zielen und Anordnungen zur Kontrolle oder Verbesserung des Zustands des Patienten, zur Planung der nächsten empfohlenen oder vereinbarten Untersuchungen, Kontrolltermine und Schulungen. Durchgeführte Maßnahmen wie Untersuchungen oder Schulungen können in der Sektion "History of Procedures" dokumentiert werden.
Short | Behandlungsplan (Plan of Care)
Control | 0..1
160. Composition.section:sectionPlanOfCare.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "18776-5" }] }`
162. Composition.section:sectionPlanOfCare.entry
Type | Reference(AT APS CarePlan, AT APS Immunization, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
164. Composition.section:sectionPlanOfCare.entry:carePlan
Slice Name | carePlan
Control | 0..*
Type | Reference(AT APS CarePlan)
166. Composition.section:sectionPlanOfCare.entry:immunizationRecommendation
Slice Name | immunizationRecommendation
Control | 0..*
Type | Reference(AT APS Immunization)
168. Composition.section:sectionPlanOfCare.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
170. Composition.section:sectionSocialHistory
Slice Name | sectionSocialHistory
Definition | Diese Sektion erfasst den aktuellen Lebensstil einer Person. Angaben zum Rauchverhalten sowie zum Alkoholkonsum werden in den hierfür vorgesehenen spezifischen Ressourcen abgebildet. Weitere relevante Aspekte, wie z.B. körperliche Aktivität, Ernährungsgewohnheiten oder sonstige Verhaltensweisen, werden mithilfe der AtApsObservation-Ressource dokumentiert.
Short | Lebensstil / Soziale Umstände und Verhalten (Social History)
Control | 0..1
172. Composition.section:sectionSocialHistory.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "29762-2" }] }`
174. Composition.section:sectionSocialHistory.entry
Type | Reference(AT APS Observation, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
176. Composition.section:sectionSocialHistory.entry:smokingTobaccoUse
Slice Name | smokingTobaccoUse
Control | 0..1
Type | Reference(AT APS Observation Tobacco Use)
178. Composition.section:sectionSocialHistory.entry:alcoholUse
Slice Name | alcoholUse
Control | 0..1
Type | Reference(AT APS Observation Alcohol Use)
180. Composition.section:sectionSocialHistory.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)
182. Composition.section:sectionVitalSigns
Slice Name | sectionVitalSigns
Definition | Die Sektion umfasst Informationen wie Blutdruck, Körpertemperatur, Herzfrequenz, Atemfrequenz, Größe, Gewicht, Body-Mass-Index, Kopfumfang oder Pulsoximetrie. Insbesondere können auffällige Vitalparameter oder körperliche Befunde wie der letzte, maximale und/oder minimale Wert, der Ausgangswert oder relevante Trends angegeben werden.
Short | Vitalparameter (Vital Signs)
Control | 0..1
184. Composition.section:sectionVitalSigns.code
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "8716-3" }] }`
186. Composition.section:sectionVitalSigns.entry
Type | Reference(AT APS Observation, AT APS DocumentReference)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
188. Composition.section:sectionVitalSigns.entry:vitalSign
Slice Name | vitalSign
Control | 0..*
Type | Reference(AT APS Observation Vital Signs)
190. Composition.section:sectionVitalSigns.entry:document
Slice Name | document
Control | 0..*
Type | Reference(AT APS DocumentReference)

Guidance on how to interpret the contents of this table can be foundhere

0. Composition
Definition | A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).
Short | AT APS Composition
Comments | While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
Control | 0..*
Is Modifier | false
Impose Profile | This profile also requires that the instance also conform this additional profile: Composition (IPS)
Summary | false
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (`contained.contained.empty()`) dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (`contained.meta.security.empty()`) dom-6: A resource should have narrative for robust management (`text.`div`.exists()`) aps-comp-1: For automatically generated APS an attester is not allowed (`(author.resolve().ofType(Device).count() != author.count() or attester.count() = 0)`)
2. Composition.id
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Short | Logical id of this artifact
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
Control | 0..1
Type | id
Is Modifier | false
Summary | true
4. Composition.meta
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Short | Metadata about the resource
Control | 0..1
Type | Meta
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
6. Composition.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Short | A set of rules under which this content was created
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Control | 0..1
Type | uri
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
8. Composition.language
Definition | The base language in which the resource is written.
Short | Language of the resource content
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages (preferred to `http://hl7.org/fhir/ValueSet/languages|4.0.1` ) A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
10. Composition.text
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Short | Text summary of the resource, for human interpretation
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Control | 0..1
Type | Narrative
Is Modifier | false
Summary | false
Alternate Names | narrative, html, xhtml, display
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
12. Composition.contained
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Short | Contained, inline Resources
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Control | 0..*
Type | Resource
Is Modifier | false
Summary | false
Alternate Names | inline resources, anonymous resources, contained resources
14. Composition.extension
Definition | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
16. Composition.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
18. Composition.identifier
Definition | A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.
Short | Version-independent identifier for the Composition
Comments | Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
20. Composition.status
Definition | The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.
Short | preliminary | final | amended | entered-in-error
Comments | If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.
Control | 1..1
Binding | The codes SHALL be taken from CompositionStatus (required to `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` ) The workflow/clinical status of the composition.
Type | code
Is Modifier | true because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to be able to mark interim, amended, or withdrawn compositions or documents.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
22. Composition.type
Definition | Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition.
Short | Kind of composition (LOINC if possible)
Comments | For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.
Control | 1..1
Binding | The codes SHOULD be taken from FHIRDocumentTypeCodes (preferred to `http://hl7.org/fhir/ValueSet/doc-typecodes|4.0.1` ) Type of a composition.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Key metadata element describing the composition, used in searching/filtering.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
24. Composition.category
Definition | A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.
Short | Categorization of Composition
Comments | This is a metadata field from XDS/MHD.
Control | 0..*
Binding | For example codes, see DocumentClassValueSet (example to `http://hl7.org/fhir/ValueSet/document-classcodes|4.0.1` ) High-level kind of a clinical document at a macro level.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
26. Composition.subject
Definition | Patientendaten, inkl. Angabe von Kontaktpersonen, Hausarzt bzw. primäre Ansprechpartner.
Short | The person the Austrian Patient Summary is about.
Comments | For clinical documents, this is usually the patient.
Control | 0..1
Type | Reference(AT APS Patient)
Is Modifier | false
Summary | true
Requirements | Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
28. Composition.encounter
Definition | Describes the clinical encounter or type of care this documentation is associated with.
Short | Context of the Composition
Control | 0..1
Type | Reference(Encounter)
Is Modifier | false
Summary | true
Requirements | Provides context for the composition and supports searching.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
30. Composition.date
Definition | The composition editing time, when the composition was last logically changed by the author.
Short | Composition editing time
Comments | The Last Modified Date on the composition may be after the date of the document was attested without being changed.
Control | 1..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
32. Composition.author
Definition | Autor der Austrian Patient Summary. Ggf. Angabe eines Devices z.B. bei automatischer Erstellung der Patient Summary durch die zentrale Anwendung.
Short | Autor der Austrian Patient Summary
Control | 1..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | true
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
34. Composition.title
Definition | Official human-readable label for the composition.
Short | Human Readable name/title
Comments | For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
36. Composition.confidentiality
Definition | The code specifying the level of confidentiality of the Composition.
Short | As defined by affinity domain
Comments | The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not.
Control | 0..1
Binding | The codes SHALL be taken from v3.ConfidentialityClassification (2014-03-26) (required to `http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26` ) Codes specifying the level of confidentiality of the composition.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
38. Composition.attester
Definition | Person, die die Richtigkeit der Zusammenstellung bestätigt. Darf bei automatischer Erstellung durch ein Device nicht angegeben werden.
Short | Person, die die Richtigkeit der Zusammenstellung bestätigt.
Comments | Only list each attester once.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Identifies responsibility for the accuracy of the composition content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
40. Composition.attester.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
42. Composition.attester.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
44. Composition.attester.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
46. Composition.attester.mode
Definition | The type of attestation the authenticator offers.
Short | personal | professional | legal | official
Control | 1..1
Binding | The codes SHALL be taken from CompositionAttestationMode (required to `http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1` ) The way in which a person authenticated a composition.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Indicates the level of authority of the attestation.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
48. Composition.attester.time
Definition | When the composition was attested by the party.
Short | When the composition was attested
Control | 0..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
50. Composition.attester.party
Definition | Who attested the composition in the specified way.
Short | Who attested the composition
Control | 0..1
Type | Reference(AT APS Patient, RelatedPerson, AT APS Practitioner, AT APS PractitionerRole, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who has taken on the responsibility for accuracy of the composition content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
52. Composition.custodian
Definition | Organisation, die die Patient Summary verwaltet (z.B. zentrale Anwendung).
Short | Organisation, die die Patient Summary verwaltet (z.b. zentrale Anwendung).
Comments | This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.
Control | 1..1
Type | Reference(AT APS Organization)
Is Modifier | false
Summary | true
Requirements | Identifies where to go to find the current version, where to report issues, etc.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
54. Composition.relatesTo
Definition | Relationships that this composition has with other compositions or documents that already exist.
Short | Relationships to other compositions/documents
Comments | A document is a version specific composition.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
56. Composition.relatesTo.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
58. Composition.relatesTo.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
60. Composition.relatesTo.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
62. Composition.relatesTo.code
Definition | The type of relationship that this composition has with anther composition or document.
Short | replaces | transforms | signs | appends
Comments | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.
Control | 1..1
Binding | The codes SHALL be taken from DocumentRelationshipType (required to `http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1` ) The type of relationship between documents.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
64. Composition.relatesTo.target[x]
Definition | The target composition/document of this relationship.
Short | Target of the relationship
Control | 1..1
Type | Choice of: Identifier, Reference(AT APS Composition)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
66. Composition.event
Definition | The clinical service, such as a colonoscopy or an appendectomy, being documented.
Short | The clinical service(s) being documented
Comments | The event needs to be consistent with the type element, though can provide further information if desired.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | true
Requirements | Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
68. Composition.event.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
70. Composition.event.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
72. Composition.event.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
74. Composition.event.code
Definition | This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.
Short | Code(s) that apply to the event being documented
Comments | An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries.
Control | 0..*
Binding | For example codes, see v3 Code System ActCode (example to `http://terminology.hl7.org/ValueSet/v3-ActCode` ) This list of codes represents the main clinical acts being documented.
Type | CodeableConcept
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
76. Composition.event.period
Definition | The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.
Short | The period covered by the documentation
Control | 0..1
Type | Period
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
78. Composition.event.detail
Definition | The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.
Short | The event(s) being documented
Control | 0..*
Type | Reference(Resource)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
80. Composition.section
Definition | The root of the sections that make up the composition.
Short | Composition is broken into sections
Control | 5..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ code
82. Composition.section.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
84. Composition.section.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
86. Composition.section.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
88. Composition.section.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
90. Composition.section.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 0..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
92. Composition.section.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
94. Composition.section.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
96. Composition.section.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
98. Composition.section.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
100. Composition.section.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
102. Composition.section.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
104. Composition.section.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
106. Composition.section.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
108. Composition.section:sectionProblems
Slice Name | sectionProblems
Definition | Diese Sektion listet und beschreibt klinische Probleme oder Erkrankungen (kodierte Diagnosen), die derzeit für den Patienten relevant sind bzw. liefert Information über das Nichtvorhandensein.
Short | Gesundheitsprobleme und Risiken (Problems)
Control | 1..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
110. Composition.section:sectionProblems.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
112. Composition.section:sectionProblems.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
114. Composition.section:sectionProblems.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
116. Composition.section:sectionProblems.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
118. Composition.section:sectionProblems.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "11450-4" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
120. Composition.section:sectionProblems.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
122. Composition.section:sectionProblems.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
124. Composition.section:sectionProblems.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
126. Composition.section:sectionProblems.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
128. Composition.section:sectionProblems.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
130. Composition.section:sectionProblems.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Condition, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
132. Composition.section:sectionProblems.entry:problem
Slice Name | problem
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Condition)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
134. Composition.section:sectionProblems.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
136. Composition.section:sectionProblems.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
138. Composition.section:sectionProblems.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
140. Composition.section:sectionAllergies
Slice Name | sectionAllergies
Definition | In dieser Sektion werden die relevanten Allergien oder Unverträglichkeiten des Patienten dokumentiert, wobei die Art der Reaktion (z.B. Ausschlag, Anaphylaxie usw.), vorzugsweise die auslösenden Stoffe, sowie optional die Kritikalität und die Bestimmtheit der Allergie beschrieben werden. Zumindest sollten die derzeit aktiven und alle relevanten früheren Allergien und Nebenwirkungen aufgeführt werden. Liegen keine Informationen über Allergien vor oder sind keine Allergien bekannt, sollte dies ebenfalls dokumentiert werden.
Short | Allergien und Intoleranzen (Allergies and Intolerances)
Control | 1..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
142. Composition.section:sectionAllergies.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
144. Composition.section:sectionAllergies.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
146. Composition.section:sectionAllergies.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
148. Composition.section:sectionAllergies.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
150. Composition.section:sectionAllergies.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "48765-2" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
152. Composition.section:sectionAllergies.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
154. Composition.section:sectionAllergies.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
156. Composition.section:sectionAllergies.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
158. Composition.section:sectionAllergies.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
160. Composition.section:sectionAllergies.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
162. Composition.section:sectionAllergies.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS AllergyIntolerance, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
164. Composition.section:sectionAllergies.entry:allergyOrIntolerance
Slice Name | allergyOrIntolerance
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS AllergyIntolerance)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
166. Composition.section:sectionAllergies.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
168. Composition.section:sectionAllergies.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
170. Composition.section:sectionAllergies.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
172. Composition.section:sectionMedications
Slice Name | sectionMedications
Definition | Diese Sektion enthält eine Beschreibung der aktuell relevanten Medikamente des Patienten bzw. liefert Information über das Nichtvorhandensein. Dabei werden nur rezeptpflichtige Medikamente und wechselwirkungsrelevante OTCs berücksichtigt.
Short | Medikationsliste (Medication Summary)
Control | 1..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
174. Composition.section:sectionMedications.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
176. Composition.section:sectionMedications.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
178. Composition.section:sectionMedications.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
180. Composition.section:sectionMedications.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
182. Composition.section:sectionMedications.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "10160-0" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
184. Composition.section:sectionMedications.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
186. Composition.section:sectionMedications.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
188. Composition.section:sectionMedications.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
190. Composition.section:sectionMedications.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
192. Composition.section:sectionMedications.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
194. Composition.section:sectionMedications.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS MedicationStatement, AT APS MedicationRequest, AT APS MedicationAdministration, AT APS MedicationDispense, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
196. Composition.section:sectionMedications.entry:medicationStatement
Slice Name | medicationStatement
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS MedicationStatement)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
198. Composition.section:sectionMedications.entry:medicationRequest
Slice Name | medicationRequest
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS MedicationRequest)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
200. Composition.section:sectionMedications.entry:medicationAdministration
Slice Name | medicationAdministration
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS MedicationAdministration)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
202. Composition.section:sectionMedications.entry:medicationDispense
Slice Name | medicationDispense
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS MedicationDispense)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
204. Composition.section:sectionMedications.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
206. Composition.section:sectionMedications.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
208. Composition.section:sectionMedications.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
210. Composition.section:sectionProceduresHx
Slice Name | sectionProceduresHx
Definition | Diese Sektion enthält eine Beschreibung früherer Eingriffe und Therapien. Darunter fallen zum Beispiel invasive diagnostische Verfahren (z.B. Herzkatheteruntersuchung), therapeutische Verfahren (z.B. Dialyse) und chirurgische Eingriffe (z.B. Appendektomie). Befunde und Dokumentation von z.B. im Rahmen von Disease-Management-Programmen durchgeführten Schulungen und Beratungen werden ebenfalls in dieser Sektion aufgenommen. Die Dokumentation der Information kann am Beispiel der Integrierten Versorgung z.B. der Fallkoordinator übernehmen.
Short | Eingriffe und Therapien (History of Procedures)
Control | 1..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ips-comp-1: Either section.entry or emptyReason are present (`(entry.reference.exists() or emptyReason.exists())`)
212. Composition.section:sectionProceduresHx.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
214. Composition.section:sectionProceduresHx.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
216. Composition.section:sectionProceduresHx.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
218. Composition.section:sectionProceduresHx.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
220. Composition.section:sectionProceduresHx.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "47519-4" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
222. Composition.section:sectionProceduresHx.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
224. Composition.section:sectionProceduresHx.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
226. Composition.section:sectionProceduresHx.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
228. Composition.section:sectionProceduresHx.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
230. Composition.section:sectionProceduresHx.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
232. Composition.section:sectionProceduresHx.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Procedure, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
234. Composition.section:sectionProceduresHx.entry:procedure
Slice Name | procedure
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Procedure)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
236. Composition.section:sectionProceduresHx.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
238. Composition.section:sectionProceduresHx.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
240. Composition.section:sectionProceduresHx.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
242. Composition.section:sectionMedicalDevices
Slice Name | sectionMedicalDevices
Definition | Diese Sektion enthält Informationen und kodierte Einträge, die den Gebrauch von Medizinprodukten in der Krankengeschichte beschreiben, z.B. Insulinpumpen oder Herzschrittmacher.
Short | Implantate, medizinische Geräte (Medical Devices)
Control | 1..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ips-comp-1: Either section.entry or emptyReason are present (`(entry.reference.exists() or emptyReason.exists())`)
244. Composition.section:sectionMedicalDevices.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
246. Composition.section:sectionMedicalDevices.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
248. Composition.section:sectionMedicalDevices.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
250. Composition.section:sectionMedicalDevices.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
252. Composition.section:sectionMedicalDevices.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "46264-8" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
254. Composition.section:sectionMedicalDevices.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
256. Composition.section:sectionMedicalDevices.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
258. Composition.section:sectionMedicalDevices.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
260. Composition.section:sectionMedicalDevices.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
262. Composition.section:sectionMedicalDevices.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
264. Composition.section:sectionMedicalDevices.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DeviceUseStatement, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
266. Composition.section:sectionMedicalDevices.entry:deviceStatement
Slice Name | deviceStatement
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DeviceUseStatement)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
268. Composition.section:sectionMedicalDevices.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
270. Composition.section:sectionMedicalDevices.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
272. Composition.section:sectionMedicalDevices.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
274. Composition.section:sectionImmunizations
Slice Name | sectionImmunizations
Definition | Die Sektion beschreibt den aktuellen Impfstatus des Patienten und die dazugehörige Impfhistorie.
Short | Impfungen (Immunizations)
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
276. Composition.section:sectionImmunizations.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
278. Composition.section:sectionImmunizations.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
280. Composition.section:sectionImmunizations.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
282. Composition.section:sectionImmunizations.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
284. Composition.section:sectionImmunizations.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "11369-6" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
286. Composition.section:sectionImmunizations.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
288. Composition.section:sectionImmunizations.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
290. Composition.section:sectionImmunizations.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
292. Composition.section:sectionImmunizations.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
294. Composition.section:sectionImmunizations.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
296. Composition.section:sectionImmunizations.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Immunization, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
298. Composition.section:sectionImmunizations.entry:immunization
Slice Name | immunization
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Immunization)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
300. Composition.section:sectionImmunizations.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
302. Composition.section:sectionImmunizations.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
304. Composition.section:sectionImmunizations.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
306. Composition.section:sectionResults
Slice Name | sectionResults
Definition | Die Sektion fasst Untersuchungsergebnisse zusammen, die am Patienten erhoben oder anhand von biologischen In-vitro-Proben erstellt wurden. Dabei kann es sich um Laborergebnisse, Ergebnisse der anatomischen Pathologie oder um radiologische Ergebnisse handeln.
Short | Diagnostische Resultate (Results)
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
308. Composition.section:sectionResults.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
310. Composition.section:sectionResults.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
312. Composition.section:sectionResults.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
314. Composition.section:sectionResults.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
316. Composition.section:sectionResults.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "30954-2" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
318. Composition.section:sectionResults.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
320. Composition.section:sectionResults.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
322. Composition.section:sectionResults.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
324. Composition.section:sectionResults.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
326. Composition.section:sectionResults.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
328. Composition.section:sectionResults.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation, AT APS DiagnosticReport, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: type @ resolve() profile @ resolve()
330. Composition.section:sectionResults.entry:resultsObservationLaboratoryPathology
Slice Name | resultsObservationLaboratoryPathology
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Results Laboratory Pathology)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
332. Composition.section:sectionResults.entry:resultsObservationRadiology
Slice Name | resultsObservationRadiology
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Results Radiology)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
334. Composition.section:sectionResults.entry:resultsDiagnosticReport
Slice Name | resultsDiagnosticReport
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DiagnosticReport)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
336. Composition.section:sectionResults.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
338. Composition.section:sectionResults.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
340. Composition.section:sectionResults.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
342. Composition.section:sectionAdvanceDirectives
Slice Name | sectionAdvanceDirectives
Definition | Die Sektion kann aktuelle Verfügungen von Patienten beinhalten.
Short | Willenserklärungen und andere juridische Dokumente (Advance Directives)
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
344. Composition.section:sectionAdvanceDirectives.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
346. Composition.section:sectionAdvanceDirectives.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
348. Composition.section:sectionAdvanceDirectives.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
350. Composition.section:sectionAdvanceDirectives.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
352. Composition.section:sectionAdvanceDirectives.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "42348-3" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
354. Composition.section:sectionAdvanceDirectives.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
356. Composition.section:sectionAdvanceDirectives.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
358. Composition.section:sectionAdvanceDirectives.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
360. Composition.section:sectionAdvanceDirectives.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
362. Composition.section:sectionAdvanceDirectives.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
364. Composition.section:sectionAdvanceDirectives.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Consent, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
366. Composition.section:sectionAdvanceDirectives.entry:advanceDirectivesConsent
Slice Name | advanceDirectivesConsent
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Consent)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
368. Composition.section:sectionAdvanceDirectives.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
370. Composition.section:sectionAdvanceDirectives.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
372. Composition.section:sectionAdvanceDirectives.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
374. Composition.section:sectionAlerts
Slice Name | sectionAlerts
Definition | Die Sektion ermöglicht Warnmeldungen, wenn bestimmte Umstände eintreten (z.B. wenn Grenzwerte für Blutdruck, Gewicht oder subjektives Befinden einen gewissen Zeitraum überschritten werden).
Short | Warnungen (Alerts)
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
376. Composition.section:sectionAlerts.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
378. Composition.section:sectionAlerts.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
380. Composition.section:sectionAlerts.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
382. Composition.section:sectionAlerts.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
384. Composition.section:sectionAlerts.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "104605-1" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
386. Composition.section:sectionAlerts.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
388. Composition.section:sectionAlerts.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
390. Composition.section:sectionAlerts.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
392. Composition.section:sectionAlerts.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
394. Composition.section:sectionAlerts.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
396. Composition.section:sectionAlerts.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Flag Alert, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
398. Composition.section:sectionAlerts.entry:alertsFlag
Slice Name | alertsFlag
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Flag Alert)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
400. Composition.section:sectionAlerts.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
402. Composition.section:sectionAlerts.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
404. Composition.section:sectionAlerts.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
406. Composition.section:sectionFunctionalStatus
Slice Name | sectionFunctionalStatus
Definition | Diese Sektion enthält eine Beschreibung der Mobilität bzw. Fähigkeit der Patientin oder des Patienten, Handlungen des täglichen Lebens auszuführen, einschließlich möglicher Bedürfnisse. Hier könnte auch die Pflegestufe dokumentiert werden.
Short | Beeinträchtigungen (Functional Status)
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
408. Composition.section:sectionFunctionalStatus.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
410. Composition.section:sectionFunctionalStatus.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
412. Composition.section:sectionFunctionalStatus.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
414. Composition.section:sectionFunctionalStatus.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
416. Composition.section:sectionFunctionalStatus.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "47420-5" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
418. Composition.section:sectionFunctionalStatus.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
420. Composition.section:sectionFunctionalStatus.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
422. Composition.section:sectionFunctionalStatus.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
424. Composition.section:sectionFunctionalStatus.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
426. Composition.section:sectionFunctionalStatus.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
428. Composition.section:sectionFunctionalStatus.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Condition, AT APS ClinicalImpression, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
430. Composition.section:sectionFunctionalStatus.entry:disability
Slice Name | disability
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Condition)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
432. Composition.section:sectionFunctionalStatus.entry:functionalAssessment
Slice Name | functionalAssessment
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS ClinicalImpression)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
434. Composition.section:sectionFunctionalStatus.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
436. Composition.section:sectionFunctionalStatus.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
438. Composition.section:sectionFunctionalStatus.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
440. Composition.section:sectionPastIllnessHx
Slice Name | sectionPastIllnessHx
Definition | Die Sektion enthält eine Beschreibung der historischen klinischen Probleme oder Erkrankungen, die für die Patientin oder den Patienten in der Vergangenheit diagnostiziert wurden.
Short | Vergangene Gesundheitsprobleme und Risiken (History of Past Problems)
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
442. Composition.section:sectionPastIllnessHx.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
444. Composition.section:sectionPastIllnessHx.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
446. Composition.section:sectionPastIllnessHx.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
448. Composition.section:sectionPastIllnessHx.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
450. Composition.section:sectionPastIllnessHx.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "11348-0" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
452. Composition.section:sectionPastIllnessHx.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
454. Composition.section:sectionPastIllnessHx.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
456. Composition.section:sectionPastIllnessHx.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
458. Composition.section:sectionPastIllnessHx.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
460. Composition.section:sectionPastIllnessHx.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
462. Composition.section:sectionPastIllnessHx.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Condition, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
464. Composition.section:sectionPastIllnessHx.entry:pastProblem
Slice Name | pastProblem
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Condition)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
466. Composition.section:sectionPastIllnessHx.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
468. Composition.section:sectionPastIllnessHx.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
470. Composition.section:sectionPastIllnessHx.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
472. Composition.section:sectionPregnancyHx
Slice Name | sectionPregnancyHx
Definition | Die Sektion ermöglicht die Dokumentation eines Schwangerschaftsstatus inkl. geplantem Entbindungstermin und eine kurze Zusammenfassung von vergangenen Schwangerschaften.
Short | Schwangerschaftshistorie (History of Pregnancy)
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
474. Composition.section:sectionPregnancyHx.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
476. Composition.section:sectionPregnancyHx.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
478. Composition.section:sectionPregnancyHx.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
480. Composition.section:sectionPregnancyHx.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
482. Composition.section:sectionPregnancyHx.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "10162-6" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
484. Composition.section:sectionPregnancyHx.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
486. Composition.section:sectionPregnancyHx.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
488. Composition.section:sectionPregnancyHx.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
490. Composition.section:sectionPregnancyHx.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
492. Composition.section:sectionPregnancyHx.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
494. Composition.section:sectionPregnancyHx.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Pregnancy Status, AT APS Observation Pregnancy Outcome, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
496. Composition.section:sectionPregnancyHx.entry:pregnancyStatus
Slice Name | pregnancyStatus
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Pregnancy Status)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
498. Composition.section:sectionPregnancyHx.entry:pregnancyOutcomeSummary
Slice Name | pregnancyOutcomeSummary
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Pregnancy Outcome)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
500. Composition.section:sectionPregnancyHx.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
502. Composition.section:sectionPregnancyHx.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
504. Composition.section:sectionPregnancyHx.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
506. Composition.section:sectionPatientStory
Slice Name | sectionPatientStory
Definition | Die Sektion enthält narrativen Text sowie optionale Ressourcen, die zum Ausdruck bringen, was für den Patienten wichtig ist. Dazu können Bedürfnisse, Stärken, Werte, Bedenken und Präferenzen gehören, die für Personen relevant sind, die Unterstützung und Pflege anbieten.
Short | Patientenbericht (Patient Story)
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
508. Composition.section:sectionPatientStory.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
510. Composition.section:sectionPatientStory.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
512. Composition.section:sectionPatientStory.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
514. Composition.section:sectionPatientStory.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
516. Composition.section:sectionPatientStory.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "81338-6" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
518. Composition.section:sectionPatientStory.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
520. Composition.section:sectionPatientStory.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
522. Composition.section:sectionPatientStory.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
524. Composition.section:sectionPatientStory.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
526. Composition.section:sectionPatientStory.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
528. Composition.section:sectionPatientStory.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
530. Composition.section:sectionPatientStory.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
532. Composition.section:sectionPatientStory.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
534. Composition.section:sectionPlanOfCare
Slice Name | sectionPlanOfCare
Definition | Die Sektion enthält den Behandlungsplan inkl. Vorschlägen, Zielen und Anordnungen zur Kontrolle oder Verbesserung des Zustands des Patienten, zur Planung der nächsten empfohlenen oder vereinbarten Untersuchungen, Kontrolltermine und Schulungen. Durchgeführte Maßnahmen wie Untersuchungen oder Schulungen können in der Sektion "History of Procedures" dokumentiert werden.
Short | Behandlungsplan (Plan of Care)
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
536. Composition.section:sectionPlanOfCare.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
538. Composition.section:sectionPlanOfCare.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
540. Composition.section:sectionPlanOfCare.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
542. Composition.section:sectionPlanOfCare.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
544. Composition.section:sectionPlanOfCare.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "18776-5" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
546. Composition.section:sectionPlanOfCare.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
548. Composition.section:sectionPlanOfCare.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
550. Composition.section:sectionPlanOfCare.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
552. Composition.section:sectionPlanOfCare.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
554. Composition.section:sectionPlanOfCare.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
556. Composition.section:sectionPlanOfCare.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS CarePlan, AT APS Immunization, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
558. Composition.section:sectionPlanOfCare.entry:carePlan
Slice Name | carePlan
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS CarePlan)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
560. Composition.section:sectionPlanOfCare.entry:immunizationRecommendation
Slice Name | immunizationRecommendation
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Immunization)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
562. Composition.section:sectionPlanOfCare.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
564. Composition.section:sectionPlanOfCare.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
566. Composition.section:sectionPlanOfCare.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
568. Composition.section:sectionSocialHistory
Slice Name | sectionSocialHistory
Definition | Diese Sektion erfasst den aktuellen Lebensstil einer Person. Angaben zum Rauchverhalten sowie zum Alkoholkonsum werden in den hierfür vorgesehenen spezifischen Ressourcen abgebildet. Weitere relevante Aspekte, wie z.B. körperliche Aktivität, Ernährungsgewohnheiten oder sonstige Verhaltensweisen, werden mithilfe der AtApsObservation-Ressource dokumentiert.
Short | Lebensstil / Soziale Umstände und Verhalten (Social History)
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
570. Composition.section:sectionSocialHistory.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
572. Composition.section:sectionSocialHistory.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
574. Composition.section:sectionSocialHistory.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
576. Composition.section:sectionSocialHistory.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
578. Composition.section:sectionSocialHistory.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "29762-2" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
580. Composition.section:sectionSocialHistory.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
582. Composition.section:sectionSocialHistory.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
584. Composition.section:sectionSocialHistory.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
586. Composition.section:sectionSocialHistory.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
588. Composition.section:sectionSocialHistory.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
590. Composition.section:sectionSocialHistory.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
592. Composition.section:sectionSocialHistory.entry:smokingTobaccoUse
Slice Name | smokingTobaccoUse
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..1 This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Tobacco Use)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
594. Composition.section:sectionSocialHistory.entry:alcoholUse
Slice Name | alcoholUse
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..1 This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Alcohol Use)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
596. Composition.section:sectionSocialHistory.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
598. Composition.section:sectionSocialHistory.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
600. Composition.section:sectionSocialHistory.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
602. Composition.section:sectionVitalSigns
Slice Name | sectionVitalSigns
Definition | Die Sektion umfasst Informationen wie Blutdruck, Körpertemperatur, Herzfrequenz, Atemfrequenz, Größe, Gewicht, Body-Mass-Index, Kopfumfang oder Pulsoximetrie. Insbesondere können auffällige Vitalparameter oder körperliche Befunde wie der letzte, maximale und/oder minimale Wert, der Ausgangswert oder relevante Trends angegeben werden.
Short | Vitalparameter (Vital Signs)
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | cmp-1: A section must contain at least one of text, entries, or sub-sections (`text.exists() or entry.exists() or section.exists()`) cmp-2: A section can only have an emptyReason if it is empty (`emptyReason.empty() or entry.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
604. Composition.section:sectionVitalSigns.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
606. Composition.section:sectionVitalSigns.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
608. Composition.section:sectionVitalSigns.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
610. Composition.section:sectionVitalSigns.title
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.
Short | Label for section (e.g. for ToC)
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.
Alternate Names | header, label, caption
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
612. Composition.section:sectionVitalSigns.code
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title.
Short | Classification of section (recommended)
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.
Control | 1..1
Binding | For example codes, see DocumentSectionCodes (example to `http://hl7.org/fhir/ValueSet/doc-section-codes|4.0.1` ) Classification of a section of a composition/document.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Provides computable standardized labels to topics within the document.
Pattern Value | `{ "coding" : [{ "system" : "http://loinc.org", "code" : "8716-3" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
614. Composition.section:sectionVitalSigns.author
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in.
Short | Who and/or what authored the section
Control | 0..*
Type | Reference(AT APS Practitioner, AT APS PractitionerRole, AT APS Device, AT APS Patient, RelatedPerson, AT APS Organization)
Is Modifier | false
Summary | false
Requirements | Identifies who is responsible for the content.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
616. Composition.section:sectionVitalSigns.focus
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).
Short | Who/what the section is about, when it is not about the subject of composition
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
Control | 0..1
Type | Reference(Resource)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
618. Composition.section:sectionVitalSigns.text
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.
Short | Text summary of the section, for human interpretation
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: cmp-1
Type | Narrative
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
620. Composition.section:sectionVitalSigns.mode
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Short | working | snapshot | changes
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Control | 0..1
Binding | The codes SHALL be taken from ListMode (required to `http://hl7.org/fhir/ValueSet/list-mode|4.0.1` ) The processing mode that applies to this section.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
622. Composition.section:sectionVitalSigns.orderedBy
Definition | Specifies the order applied to the items in the section entries.
Short | Order of section entries
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
Control | 0..1
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to `http://hl7.org/fhir/ValueSet/list-order|4.0.1` ) What order applies to the items in the entry.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
624. Composition.section:sectionVitalSigns.entry
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation, AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Composition.section.entry`. The slices areUnordered and Open, and can be differentiated using the following discriminators: profile @ resolve()
626. Composition.section:sectionVitalSigns.entry:vitalSign
Slice Name | vitalSign
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS Observation Vital Signs)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
628. Composition.section:sectionVitalSigns.entry:document
Slice Name | document
Definition | A reference to the actual resource from which the narrative in the section is derived.
Short | A reference to data that supports this section
Comments | If there are no entries in the list, an emptyReason SHOULD be provided.
Control | 0..* This element is affected by the following invariants: cmp-2
Type | Reference(AT APS DocumentReference)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
630. Composition.section:sectionVitalSigns.emptyReason
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.
Short | Why the section is empty
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.
Control | 0..1 This element is affected by the following invariants: cmp-2
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to `http://hl7.org/fhir/ValueSet/list-empty-reason|4.0.1` ) If a section is empty, why it is empty.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
632. Composition.section:sectionVitalSigns.section
Definition | A nested sub-section within this section.
Short | Nested Section
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document.
Control | 0..* This element is affected by the following invariants: cmp-1
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)