StructureDefinition-Composition-uv-ips

Sourcehl7.fhir.uv.ips#current:International Patient Summary Implementation Guide (v4.0.1)
resourceTypeStructureDefinition
idComposition-uv-ips
canonicalhttp://hl7.org/fhir/uv/ips/StructureDefinition/Composition-uv-ips
version1.1.0
statusactive
publisherHealth Level Seven International - Patient Care Work Group
nameCompositionUvIps
titleComposition (IPS)
date2022-12-07T16:31:31+00:00
descriptionClinical document used to represent the International Patient Summary (IPS) data set. An International Patient Summary (IPS) document is an electronic health record extract containing essential healthcare information about a subject of care. The IPS dataset is minimal and non-exhaustive; specialty-agnostic and condition-independent; but still clinically relevant. As specified in EN 17269 and ISO 27269, it is designed for supporting the use case scenario for ‘unplanned, cross border care’, but it is not limited to it. It is intended to be international, i.e., to provide generic solutions for global application beyond a particular region or country. This profile is based on the ClinicalDocument profile.
copyrightHL7 International
jurisdictionsuv
fhirVersion4.0.1
kindresource
abstractfalse
sdTtypeComposition
derivationconstraint
basehttp://hl7.org/fhir/StructureDefinition/clinicaldocument
Usages
Name Flags Card. Type Description & Constraints doco
. . Composition ClinicalDocument International Patient Summary composition
. . . text S
. . . identifier S
. . . status S
. . . type S CodeableConcept 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 1.. Reference (Patient (IPS))
. . . . reference S 1..
. . . encounter
. . . date S
. . . author S Who and/or what authored the IPS
. . . title S International Patient Summary
. . . confidentiality
. . . attester S
. . . . mode S
. . . . time S
. . . . party S
. . . custodian S
. . . relatesTo
. . . . code
. . . . target[x]
. . . . . targetIdentifier Identifier
. . . . . targetReference Reference ( Composition | Composition (IPS))
. . . Slices for event Slice: Unordered, Open by pattern:code
. . . . event:careProvisioningEvent S ..1 The care provisioning being documented
. . . . . code S 1..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 IPS
Slice: Unordered, Open by pattern:code
. . . . section:All Slices Content/Rules for all slices
. . . . . code S 1.. CodeableConcept
. . . . . text S 1..
. . . . . emptyReason .. 0
. . . . . section .. 0
. . . . section:sectionMedications S 1..1 IPS Medication Summary Section
. . . . . title S 1.. Medication Summary section
. . . . . 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
. . . . . Slices for entry S 1 .. Reference ( MedicationStatement | MedicationRequest | MedicationAdministration | MedicationDispense | DocumentReference ) Medications relevant for the scope of the patient summary
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:medicationStatement Reference (Medication Statement (IPS))
. . . . . . entry:medicationRequest Reference (Medication Request (IPS))
. . . . section:sectionAllergies S 1..1 IPS Allergies and Intolerances Section
. . . . . 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
. . . . . Slices for entry S 1 .. Reference ( AllergyIntolerance | DocumentReference ) Relevant allergies or intolerances (conditions) for that patient.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:allergyOrIntolerance S 1.. Reference (Allergy Intolerance (IPS))
. . . . section:sectionProblems S 1..1 IPS Problems Section
. . . . . 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
. . . . . Slices for entry S 1 .. Reference ( Condition | DocumentReference ) Clinical problems or conditions currently being monitored for the patient.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:problem S 1.. Reference (Condition (IPS))
. . . . section:sectionProceduresHx S ..1 IPS History of Procedures Section
. . . . . 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: 47519-4
. . . . . Slices for entry S 1 .. Reference ( Procedure | DocumentReference ) Patient past procedures pertinent to the scope of this document.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:procedure S 1.. Reference (Procedure (IPS))
. . . . section:sectionImmunizations S ..1 IPS Immunizations Section
. . . . . 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: 11369-6
. . . . . Slices for entry S 1 .. Reference ( Immunization | DocumentReference ) Patient's immunization status and pertinent history.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:immunization S 1.. Reference (Immunization (IPS))
. . . . section:sectionMedicalDevices S ..1 IPS Medical Devices Section
. . . . . 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: 46264-8
. . . . . Slices for entry S 1 .. Reference ( DeviceUseStatement | DocumentReference ) Patient history of medical device use.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:deviceStatement S 1.. Reference (Device Use Statement (IPS))
. . . . section:sectionResults S ..1 IPS Results Section
. . . . . 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: 30954-2
. . . . . Slices for entry S 1 .. Reference ( Observation | DiagnosticReport | DocumentReference ) Relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient.
Slice: Unordered, Open by type:resolve(), profile:resolve()
. . . . . . entry:results-observation S Reference (Observation Results (IPS))
. . . . . . entry:results-diagnosticReport S Reference (DiagnosticReport (IPS))
. . . . section:sectionVitalSigns ..1 IPS Vital Signs Section
. . . . . title 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
. . . . . Slices for entry Reference ( Observation | DocumentReference ) Notable vital signs or physical findings.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:vitalSign Reference ( Vital Signs Profile )
. . . . section:sectionPastIllnessHx ..1 IPS History of Past Illness Section
. . . . . title 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: 11348-0
. . . . . Slices for entry 1 .. Reference ( Condition | DocumentReference ) Conditions the patient suffered in the past.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:pastProblem 1.. Reference (Condition (IPS))
. . . . section:sectionFunctionalStatus ..1 IPS Functional Status
. . . . . title 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: 47420-5
. . . . . Slices for entry Reference ( Condition | ClinicalImpression | DocumentReference ) Optional entry used to represent disabilities and functional assessments
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:disability Reference (Condition (IPS))
. . . . . . entry:functionalAssessment Reference ( ClinicalImpression )
. . . . section:sectionPlanOfCare ..1 IPS Plan of Care Section
. . . . . title 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: 18776-5
. . . . . Slices for entry Reference ( CarePlan | DocumentReference ) Optional entry used to represent structured care plans
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:carePlan Reference ( CarePlan )
. . . . section:sectionSocialHistory ..1 IPS Social History Section
. . . . . title 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: 29762-2
. . . . . Slices for entry Reference ( Observation | DocumentReference ) Health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.)
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:smokingTobaccoUse ..1 Reference (Observation - SH: tobacco use)
. . . . . . entry:alcoholUse ..1 Reference (Observation - SH: alcohol use)
. . . . section:sectionPregnancyHx ..1 IPS History of Pregnancy Section
. . . . . title 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
. . . . . Slices for entry Reference ( Observation | DocumentReference ) Current pregnancy status and, optionally, information about the outcome of earlier pregnancies.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:pregnancyStatus Reference (Observation - Pregnancy: status)
. . . . . . entry:pregnancyOutcomeSummary Reference (Observation - Pregnancy: outcome)
. . . . section:sectionAdvanceDirectives ..1 IPS Advance Directives Section
. . . . . title 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: 42348-3
. . . . . Slices for entry Reference ( Consent | DocumentReference ) Narrative description of the patient's advance directive.
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:advanceDirectivesConsent Reference ( Consent )

doco Documentation for this format

Produced 08 Sep 2023