StructureDefinition-composition-ca-ps

Sourceca.infoway.io.psca#1.0.1-alpha3:Pan-Canadian Patient Summary (v4.0.1)
resourceTypeStructureDefinition
idcomposition-ca-ps
canonicalhttp://fhir.infoway-inforoute.ca/io/psca/StructureDefinition/composition-ca-ps
version1.0.0
statusdraft
publisherCanada Health Infoway
nameCompositionPSCA
titleComposition (PS-CA)
date2022-03-28T01:23:00-08:00
experimentalfalse
descriptionThis profile represents the constraints applied to the Composition resource by the PS-CA project. A Canadian Patient Summary (PS-CA) document is an electronic health record extract containing essential healthcare information about a subject of care. It is informed by the IPS-UV Composition profile, but differs in its application of Must Support flags on some of the sections to allow for jurisdictional implementors flexibility in what sections systems Must Support in order to show conformance to their respective patient summaries. The PS-CA dataset is minimal and non-exhaustive; specialty-agnostic and condition-independent; but still clinically relevant. Its informed by the requirements specified in EN 17269 and ISO/DIS 27269, it is designed for supporting the international use case scenario for ‘unplanned, cross border care’, but is also designed to support a variety of use cases for cross-jurisdiction exchange. It is intended to guide implementation nationally while ensuring international exchange of patient summaries is not impeded. This profile is based on the ClinicalDocument profile from the base R4 FHIR standard.
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jurisdictionsca
fhirVersion4.0.1
kindresource
abstractfalse
sdTtypeComposition
derivationconstraint
basehttp://hl7.org/fhir/StructureDefinition/clinicaldocument
Usages
Name Flags Card. Type Description & Constraints doco
. . Composition ClinicalDocument Canadian Patient Summary composition
. . . text S
. . . identifier S
. . . status S
. . . type S 1.. Kind of composition ("Patient 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: 60591-5
. . . subject S Reference (Patient (PS-CA))
. . . . reference S 1..
. . . encounter
. . . date S
. . . author S Reference (Practitioner Profile (General) | PractitionerRole Profile (General) | Device | Patient (PS-CA) | RelatedPerson | Organization Profile) Who and/or what authored the patient summary
. . . title S CA Patient Summary
. . . confidentiality
. . . attester S
. . . . mode S
. . . . time S
. . . . party S Reference (Patient (PS-CA) | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile)
. . . custodian S Reference (Organization Profile)
. . . relatesTo
. . . . code
. . . . target[x]
. . . . . targetIdentifier Identifier
. . . . . targetReference Reference ( Composition | Composition (PS-CA))
. . . Slices for event Slice: Unordered, Open by pattern:code
. . . . event:careProvisioningEvent ..1 The care provisioning being documented
. . . . . code S 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://terminology.hl7.org/CodeSystem/v3-ActClass
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: PCPR
. . . . . period S
. . . Slices for section S 1 .. Sections composing the PS
Slice: Unordered, Open by pattern:code
. . . . section:All Slices Content/Rules for all slices
. . . . . code S 1.. CodeableConcept
. . . . . text S 1..
. . . . section:sectionMedications S 1..1 PS-CA Medication Summary Section
. . . . . title S 1.. Medication Summary section
. . . . . code S 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
. . . . . Slices for entry S 1 .. Medications relevant for the scope of the patient summary
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:medicationStatement Reference (Medication Statement (PS-CA)) A reference to data that supports this section
. . . . . . entry:medicationRequest Reference (Medication Request (PS-CA)) A reference to data that supports this section
. . . . . . entry:MedicationSectionNotSupported Reference (Medication Statement Content Not Supported (PS-CA)) A reference to a resource with fixed elements indicating lack of support of this section
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionAllergies S 1..1 PS-CA Allergies and Intolerances Section
. . . . . title S 1.. Allergies and Intolerances
. . . . . code S 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
. . . . . Slices for entry S 1 .. Relevant allergies or intolerances (conditions) for that patient.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:allergyOrIntolerance 1..* Reference (Allergy Intolerance (PS-CA)) A reference to data that supports this section
. . . . . . entry:AllergySectionNotSupported Reference (Allergy Intolerance Content Not Supported (PS-CA)) A reference to a resource with fixed elements indicating lack of support of this section
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionProblems S 1..1 PS-CA Problems Section
. . . . . title S 1..
. . . . . code S 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
. . . . . Slices for entry S 1 .. Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:problem Reference (Condition (PS-CA)) A reference to data that supports this section
. . . . . . entry:ProblemSectionNotSupported Reference (Condition Content Not Supported (PS-CA)) A reference to a resource with fixed elements indicating lack of support of this section
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionProceduresHx ..1 PS-CA History of Procedures Section
. . . . . title S 1..
. . . . . code S 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
. . . . . Slices for entry S 1 .. Patient past procedures pertinent to the scope of this document.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:procedure S 1.. Reference (Procedure (PS-CA))
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionImmunizations ..1 PS-CA Immunizations Section
. . . . . title S 1..
. . . . . code S 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
. . . . . Slices for entry S 1 .. Patient's immunization status and pertinent history.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:immunization S 1.. Reference (Immunization (PS-CA))
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionMedicalDevices ..1 PS-CA Medical Devices Section
. . . . . title S 1..
. . . . . code S 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
. . . . . Slices for entry S 1 .. Patient history of medical device use.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:deviceStatement S 1.. Reference (Device Use Statement (IPS))
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionResults ..1 PS-CA Results Section
. . . . . title S 1..
. . . . . code S 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
. . . . . Slices for entry S 1 .. Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:results-observation S Reference (Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS))
. . . . . . entry:results-diagnosticReport S Reference (DiagnosticReport (IPS))
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionVitalSigns ..1 PS-CA Vital Signs Section
. . . . . title S 1..
. . . . . code S 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
. . . . . Slices for entry S Notable vital signs or physical findings.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:BMI Reference ( Observation Body Mass Index Profile )
. . . . . . entry:BP Reference ( Observation Blood Pressure Profile )
. . . . . . entry:BodyHeight Reference ( Observation Body Height Profile )
. . . . . . entry:BodyTemp Reference ( Observation Body Temperature Profile )
. . . . . . entry:BodyWeight Reference ( Observation Body Weight Profile )
. . . . . . entry:HeadCircum Reference ( Observation Head Circumference Profile )
. . . . . . entry:HeartRate Reference ( Observation Heart Rate Profile )
. . . . . . entry:OxygenSat Reference ( Observation Oxygen Saturation Profile )
. . . . . . entry:RespRate Reference ( Observation Respiratory Rate Profile )
. . . . . . entry:VitalsPanel Reference ( Observation Vital Signs Panel Profile )
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionPastIllnessHx ..1 PS-CA History of Past Illness Section
. . . . . title S 1..
. . . . . code S 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
. . . . . Slices for entry S 1 .. Conditions the patient suffered in the past.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:pastProblem S 1.. Reference (Condition (PS-CA))
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionFunctionalStatus ..1 PS-CA Functional Status
. . . . . title S 1..
. . . . . code S 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: 47420-5
. . . . . Slices for entry S Optional entry used to represent disabilities and functional assessments
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:disability S Reference (Condition (PS-CA))
. . . . . . entry:functionalAssessment S Reference ( ClinicalImpression )
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionPlanOfCare ..1 PS-CA Plan of Care Section
. . . . . title S 1..
. . . . . code S 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: 18776-5
. . . . . Slices for entry Optional entry used to represent structured care plans
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:carePlan Reference ( CarePlan )
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionSocialHistory ..1 PS-CA Social History Section
. . . . . title S 1..
. . . . . code S 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
. . . . . Slices for entry S Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.)
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:generalSocialHistory Reference (SHx Observation: Social History (PS-CA))
. . . . . . entry:smokingTobaccoUse ..1 Reference (SHx Observation: Tobacco Use (PS-CA))
. . . . . . entry:alcoholUse ..1 Reference (SHx Observation: Alcohol Use (PS-CA))
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionPregnancyHx ..1 PS-CA History of Pregnancy Section
. . . . . title S 1..
. . . . . code S 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: 10162-6
. . . . . Slices for entry S Current pregnancy status and, optionally, information about the outcome of earlier pregnancies.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:pregnancyStatus S Reference (Observation - Pregnancy: status)
. . . . . . entry:pregnancyOutcomeSummary S Reference (Observation - Pregnancy: outcome)
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionAdvanceDirectives ..1 PS-CA Advance Directives Section
. . . . . title S 1..
. . . . . code S 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
. . . . . Slices for entry S Narrative description of the patient's advance directive.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:advanceDirectivesConsent S Reference ( Consent )
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionFamilyHistory ..1 PS-CA Family History Section
. . . . . title S 1..
. . . . . code S 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
. . . . . Slices for entry S Narrative description of the patient's family history.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:FamilyMemberHistory S Reference (Family Member History (PS-CA))
. . . . . emptyReason .. 0
. . . . . section .. 0

doco Documentation for this format

Produced 06 Apr 2023