Source | au.digitalhealth.r4#current:Australian Digital Health Agency FHIR Implementation Guide (v4.0.1) |
resourceType | StructureDefinition |
id | dh-composition-ds-1 |
canonical | http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-composition-ds-1 |
version | 0.0.8 |
status | draft |
publisher | Australian Digital Health Agency |
name | ADHACompositionDS |
title | ADHA Discharge Summary Composition |
date | 2023-08-11T04:00:05+00:00 |
experimental | false |
description | The purpose of this profile is to define a representation of an Discharge 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 following discharge. 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 |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | ADHACompositionDocument | Discharge Summary | ||
status | Required Pattern: final | |||
Slices for category | Slice: Unordered, Open by pattern:$this | |||
category:ds | 1..1 |
Discharge Summary 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: 18842-5 |
|
author | Reference (ADHA Authoring PractitionerRole) | |||
Slices for section | C |
Slice:
Unordered, Open by pattern:code
inv-dh-ds-01: A section shall at least have an entry or an empty reason inv-dh-ds-02: All observations shall conform one of: ADHA Simple Observation, ADHA Diagnostic Result Observation |
||
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:dischargeMedicines | C | ..1 |
Medicines on discharge inv-dh-ds-04: At most one assertion of no relevant finding shall be present inv-dh-ds-05: If a list is provided, no other entry 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: 10183-2 |
|
entry | C | Reference (ADHA Medication Use List | ADHA Core MedicationStatement | AU Core Assertion of No Relevant Finding) | ||
emptyReason | C | Binding: todo ( required ) | ||
section:admissionMedicines | C | ..1 |
Medicines on admission inv-dh-ds-08: If an assertion of no known current medications is provided, no other entry shall be present inv-dh-ds-09: If a list is provided, no other entry 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: 42346-7 |
|
entry | C | Reference (ADHA Medication Use List | ADHA Core MedicationStatement | AU Core Assertion of No Relevant Finding) | ||
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:immunisations | C | ..1 |
Immunisations inv-dh-ds-11: If an assertion of no history of immunisation is provided, no other entry shall be present inv-dh-ds-12: If a list is provided, no other entry 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-ds-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-ds-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-ds-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 ) | ||
Documentation for this format |
Produced 08 Sep 2023