Source | au.digitalhealth.r4#current:Australian Digital Health Agency FHIR Implementation Guide (v4.0.1) |
resourceType | StructureDefinition |
id | dh-composition-cocs-1 |
canonical | http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-composition-cocs-1 |
version | 0.0.5 |
status | draft |
publisher | Australian Digital Health Agency |
name | ADHACompositionCOCS |
title | ADHA Continuity of Care Summary Composition |
date | 2023-08-11T04:00:05+00:00 |
experimental | true |
description | The purpose of this profile is to define a representation of an Continuity of Care Summary document for a patient for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia. This profile standardises the core, common or critical information for exchange of information between healthcare providers, and individual, to support continuity of care across encounters and healthcare settings. Specific use cases are supported by defined profiles for those use cases such as Shared Health Summary, Event Summary, Discharge Summary, Transfer Summary, Referral; where available the most specific applicable profile should be used. A composition is a set of resources composed into a single coherent clinical statement that may have clinical attestation. |
copyright | Copyright © 2022 Australian Digital Health Agency - All rights reserved. Except for the material identified below, this content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/. This material contains content from LOINC (http://loinc.org). LOINC is copyright © 1995-2021, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://loinc.org/license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc. All copies of this resource must include this copyright statement and all information contained in this statement. |
jurisdictions | au |
fhirVersion | 4.0.1 |
kind | resource |
abstract | false |
sdTtype | Composition |
derivation | constraint |
base | http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-composition-document-1 |
Usages | (none) |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | ADHACompositionDocument | Continuity of Care Summary | ||
status | Required Pattern: final | |||
author | Reference (ADHA Authoring PractitionerRole) | |||
Slices for section | C |
Slice:
Unordered, Open by pattern:code
inv-dh-cocs-01: A section shall at least have an entry or an empty reason inv-dh-cocs-02: All observations shall conform one of: ADHA Simple Observation, ADHA Diagnostic Result Observation |
||
section:reasonForReferral | ..1 | Reason for referral | ||
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 42349-1 |
|
entry | C | Reference (ADHA Core ServiceRequest) | ||
emptyReason | C | Binding: todo ( required ) | ||
section:advanceCareDirectives | ..1 | Information on advance care directives. | ||
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 42348-3 |
|
entry | C | Reference (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-consent-core-1 | ADHA Core DocumentReference | ADHA Advance Care Planning Document DocumentReference) | ||
emptyReason | C | Binding: todo ( required ) | ||
section:allergies | ..1 | Allergies | ||
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 48765-2 |
|
entry | C | Reference (ADHA Core AllergyIntolerance) | ||
emptyReason | C | Binding: todo ( required ) | ||
section:vitalSigns | ..1 | Vital signs | ||
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 8716-3 |
|
entry | C | Reference (AU Core Vitals Panel | AU Core Blood Pressure | AU Core Body Weight | AU Core Body Height | AU Core BMI | AU Core Oxygen Saturation | AU Core Head Circumference | AU Core Heart Rate | AU Core Body Temperature | AU Core Respiration Rate) | ||
emptyReason | C | Binding: todo ( required ) | ||
section:medicines | C | ..1 |
Medicines inv-dh-cocs-04: At most one assertion of no relevant finding shall be present and it shall assert no known current medications inv-dh-cocs-05: At most one list shall be present |
|
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 10160-0 |
|
entry | C | Reference (ADHA Medication Use List | ADHA Core MedicationStatement | AU Core Assertion of No Relevant Finding) | ||
emptyReason | C | Binding: todo ( required ) | ||
section:immunisations | C | ..1 |
Immunisations inv-dh-cocs-08: At most one assertion of no relevant finding shall be present and it shall assert no history of vaccination inv-dh-cocs-09: At most one list shall be present |
|
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 11369-6 |
|
entry | C | Reference (ADHA Immunisation History List | ADHA Core Immunization | AU Core Assertion of No Relevant Finding) | ||
emptyReason | C | Binding: todo ( required ) | ||
section:problems | C | ..1 |
Problems or Diagnoses inv-dh-cocs-07: At most one list shall be present |
|
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 11450-4 |
|
entry | C | Reference (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-list-condition-1 | ADHA Core Condition) | ||
emptyReason | C | Binding: todo ( required ) | ||
section:pastMedicalHistory | C | ..1 |
Past medical history inv-dh-cocs-03: At most one list shall be present |
|
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 11348-0 |
|
entry | C | Reference (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-list-condition-1 | ADHA Core Condition) | ||
emptyReason | C | Binding: todo ( required ) | ||
section:procedures | C | ..1 |
Procedures inv-dh-cocs-06: At most one list shall be present |
|
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 47519-4 |
|
entry | C | Reference (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-list-procedure-1 | ADHA Core Procedure) | ||
emptyReason | C | Binding: todo ( required ) | ||
section:functionalStatus | ..1 | Functional Status | ||
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 46264-8 |
|
entry | C | Reference (ADHA Core Observation | ADHA Core Condition) | ||
emptyReason | C | Binding: todo ( required ) | ||
section:familyHistory | ..1 | Family History | ||
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 10157-6 |
|
entry | Reference (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-familyhistory-core-1) | |||
emptyReason | C | Binding: todo ( required ) | ||
section:socialHistory | ..1 | Social History (Lifestyle factors) | ||
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 29762-2 |
|
entry | Reference (ADHA Core Observation | AU Core Alcohol Status | AU Core Smoking Status | AU Core Smoking Start Date | AU Core Smoking Cease Date) | |||
emptyReason | C | Binding: todo ( required ) | ||
section:medicalDevices | C | ..1 |
Medical devices inv-dh-cocs-10: At most one assertion of no relevant finding shall be present |
|
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 46264-8 |
|
entry | C | Reference (ADHA Implantable Medical Device | http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-device-wearable-1 | http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-deviceusestatement-core-1 | AU Core Assertion of No Relevant Finding) | ||
emptyReason | C | Binding: todo ( required ) | ||
section:diagnosticInvestigations | 0..1 | Diagnostic Investigations (Editorial Note: The design of this section is incomplete. | ||
title | 1.. | |||
code | 1.. | Required Pattern: At least the following | ||
coding | 1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system | 1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
code | 1..1 | code |
Symbol in syntax defined by the system Fixed Value: 30954-2 |
|
entry | C | Reference (ADHA Core DiagnosticReport | ADHA Diagnostic Result Observation | ADHA Imaging Result Observation | ADHA Pathology Result Observation) | Diagnostic investigations | |
emptyReason | C | Binding: todo ( required ) | ||
Documentation for this format |
Produced 08 Sep 2023