| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
Composition
|
Composition | |||
identifier
|
S | Identificador local para recurso de documeto que puede ser distinto para cada versión del mismo | ||
|
status
|
S |
Estado, valores posibles: preliminary | final | amended | entered-in-error Required Pattern: final |
||
|
type
|
S |
Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos ( required ) |
||
subject
|
S | 1.. | Reference ( Patient ) | Paciente sobre el cual se ha generado este documento. Este debe ser basado en el perfil del paciente Chileno. |
reference
|
S | 1.. | Corresponde al paciente | |
|
encounter
|
S | Contexto del Documento. | ||
|
reference
|
S | 1.. | Corresponde al paciente | |
|
identifier
|
S | Identificador, en formato identifier para el encuentro | ||
|
display
|
S | texto que describe el contexto del documento | ||
|
date
|
S | Fecha en la cual se editó el documento | ||
|
author
|
S | ..1 | Reference ( Practitioner ) | Quien Ha creado el documento |
|
title
|
S | Título del documento generado | ||
|
attester
|
S | Validadores del documento | ||
|
mode
|
S |
Labor del Validador personal|profesional|legal|official Binding: Composition Attestation Mode ( required ) |
||
|
time
|
S | Fecha y Hora de la validación | ||
|
party
|
S | Quien validó | ||
Slices for section
|
S | 1 .. |
Sección del documento
Slice: Unordered, Open by pattern:code |
|
section:All Slices
|
Content/Rules for all slices | |||
code
|
S | 1.. | Binding: Document Section Codes ( example ) | |
section:sectionDiagnosticos
|
S | 0..* |
Sección Diagnósticos |
|
title
|
S | 1.. | ||
|
code
|
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
|
S | 1 .. | Reference ( Condition ) |
Diagnósticos conocidos actualmente de relevancia para determinaciones clínicas en el paciente.
Slice: Unordered, Open by profile:resolve() |
|
section:sectionMedicamentos
|
S | 0..* |
Sección Medicamentos |
|
|
title
|
S | 1.. | ||
|
code
|
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
|
S | 1 .. | Reference ( MedicationStatement ) |
Referencia al Medicamento Prescrito al paciente.
Slice: Unordered, Open by profile:resolve() |
|
section:sectionAlergias
|
S | 0..* |
Sección Alergias y Reacciones Adversas |
|
|
title
|
S | 1.. | ||
|
code
|
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
|
S | 1 .. | Reference ( AllergyIntolerance ) |
Alergias e Intolerancia descrita
Slice: Unordered, Open by profile:resolve() |
|
section:sectionObservacionEmbarazo
|
S | 0..* |
Sección Antecedentes de Embarazo |
|
|
title
|
S | 1.. | ||
|
code
|
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 |
|
|
entry
|
S | 1 .. | Reference ( Observation ) |
Descripción del antecedente de embarzo
Slice: Unordered, Open by profile:resolve() |
|
section:sectionObservacionSignosVitales
|
S | 0..* |
Sección de Signos Vitales Medidos |
|
|
title
|
S | 1.. | ||
|
code
|
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
|
S | 1 .. | Reference ( Observation ) |
Descripción del los signos vitales y mediciones desarrolladas
Slice: Unordered, Open by profile:resolve() |
|
Documentation for this format
|
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