| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
Composition
|
Composition | |||
status
|
S | |||
|
type
|
S | Kind of composition (SNOMED CT if possible) | ||
coding
|
1..1 | |||
|
system
|
Fixed Value: http://snomed.info/sct | |||
|
code
|
1.. | Fixed Value: 373942005 | ||
display
|
1.. | Fixed Value: Discharge summary | ||
|
text
|
S | |||
subject
|
S | 1.. | Reference (Patient) | |
|
reference
|
1.. | |||
|
encounter
|
S | 1.. | Reference (Encounter) | |
|
author
|
S | Reference ( Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | ||
|
attester
|
S | |||
|
party
|
Reference ( RelatedPerson | Practitioner | PractitionerRole | Patient | Organization) | |||
|
custodian
|
Reference (Organization) | |||
Slices for section
|
S | 1 .. | Slice: Unordered, Open At End by value:code.coding.code | |
section:ChiefComplaints
|
..1 | |||
code
|
||||
coding
|
S | ..1 | ||
|
system
|
Fixed Value: http://snomed.info/sct | |||
|
code
|
1.. | Fixed Value: 422843007 | ||
|
display
|
1.. | Fixed Value: Chief complaint section | ||
|
text
|
S | |||
entry
|
S | Reference (Condition) | ||
|
reference
|
1.. | |||
|
section:PhysicalExamination
|
..1 | |||
|
code
|
||||
|
coding
|
S | ..1 | ||
|
system
|
Fixed Value: http://snomed.info/sct | |||
|
code
|
1.. | Fixed Value: 425044008 | ||
|
display
|
1.. | Fixed Value: Physical exam section | ||
|
text
|
S | |||
|
entry
|
S | Reference (Observation) | ||
|
reference
|
1.. | |||
|
section:Allergies
|
..1 | |||
|
code
|
||||
|
coding
|
S | ..1 | ||
|
system
|
Fixed Value: http://snomed.info/sct | |||
|
code
|
1.. | Fixed Value: 722446000 | ||
|
display
|
1.. | Fixed Value: Allergy record | ||
|
text
|
S | |||
|
entry
|
S | Reference (AllergyIntolerance) | ||
|
reference
|
1.. | |||
|
section:MedicalHistory
|
..1 | |||
|
code
|
||||
|
coding
|
S | ..1 | ||
|
system
|
Fixed Value: http://snomed.info/sct | |||
|
code
|
1.. | Fixed Value: 1003642006 | ||
|
display
|
1.. | Fixed Value: Past medical history section | ||
|
text
|
S | |||
|
entry
|
S | Reference (Procedure | Condition) | ||
|
reference
|
1.. | |||
|
section:FamilyHistory
|
..1 | |||
|
code
|
||||
|
coding
|
S | ..1 | ||
|
system
|
Fixed Value: http://snomed.info/sct | |||
|
code
|
1.. | Fixed Value: 422432008 | ||
|
display
|
1.. | Fixed Value: Family history section | ||
|
text
|
S | |||
|
entry
|
S | Reference (FamilyMemberHistory) | ||
|
reference
|
1.. | |||
|
section:Investigations
|
..1 | |||
|
code
|
||||
|
coding
|
S | ..1 | ||
|
system
|
Fixed Value: http://snomed.info/sct | |||
|
code
|
1.. | Fixed Value: 721981007 | ||
|
display
|
1.. | Fixed Value: Diagnostic studies report | ||
|
text
|
S | |||
|
entry
|
S | Reference (DiagnosticReportLab | DiagnosticReportImaging) | ||
|
reference
|
1.. | |||
|
section:Medications
|
..1 | |||
|
code
|
||||
|
coding
|
S | ..1 | ||
|
system
|
Fixed Value: http://snomed.info/sct | |||
|
code
|
1.. | Fixed Value: 1003606003 | ||
|
display
|
1.. | Fixed Value: Medication history section | ||
|
text
|
S | |||
|
entry
|
S | Reference (MedicationRequest) | ||
|
reference
|
1.. | |||
|
section:Procedures
|
..1 | |||
|
code
|
||||
|
coding
|
S | ..1 | ||
|
system
|
Fixed Value: http://snomed.info/sct | |||
|
code
|
1.. | Fixed Value: 1003640003 | ||
|
display
|
1.. | Fixed Value: History of past procedure section | ||
|
text
|
S | |||
|
entry
|
S | Reference (Procedure) | ||
|
reference
|
1.. | |||
|
section:CarePlan
|
..1 | |||
|
code
|
||||
|
coding
|
S | ..1 | ||
|
system
|
Fixed Value: http://snomed.info/sct | |||
|
code
|
1.. | Fixed Value: 734163000 | ||
|
display
|
1.. | Fixed Value: Care plan | ||
|
text
|
S | |||
|
entry
|
S | Reference (CarePlan) | ||
|
reference
|
1.. | |||
section:DocumentReference
|
..1 | |||
|
code
|
||||
|
coding
|
S | ..1 | ||
|
system
|
Fixed Value: http://snomed.info/sct | |||
|
code
|
1.. | Fixed Value: 373942005 | ||
|
display
|
1.. | Fixed Value: Discharge summary | ||
|
text
|
S | |||
|
entry
|
S | Reference (DocumentReference) | ||
|
reference
|
1.. | |||
|
Documentation for this format
|
||||