Nictiz FHIR NL R4 Zib2020
0.9.0 - CI Build
Nictiz FHIR NL R4 Zib2020
0.9.0 - CI Build
Nictiz FHIR NL R4 Zib2020 - Local Development build (v0.9.0). See the Directory of published versions
| Official URL: http://nictiz.nl/fhir/StructureDefinition/zib-SOAPReport | Version: 0.9.0 | |||
| Draft as of 2023-10-17 | Computable Name: ZibSOAPReport | |||
Copyright/Legal: Copyright and related rights waived via CC0, https://creativecommons.org/publicdomain/zero/1.0/. This does not apply to information from third parties, for example a medical terminology system. The implementer alone is responsible for identifying and obtaining any necessary licenses or authorizations to utilize third party IP in connection with the specification or otherwise. |
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A SOAP report is a textual report of a (partial) consult with relation to a single problem according to the SOAP structure. SOAP (acronym for subjective, objective, assessment, plan) is a method used by health professionals to structurally record information that comes up during contact between the patient and a health professionals in the patient’s record. The following standardized format is used for reporting:
The SOAP report is mainly used in general practice care.
Note: the zib doesn’t state explicitly if zib SOAPReport pertains a consult or a partial consult, but it has become clear that the zib, and thus this profile, should be interpreted as a partial consult with relation to a single problem (see https://bits.nictiz.nl/browse/ZIB-1474). The text above has been adjusted according to this insight.
This Composition resource represents the Dutch zib (‘Zorginformatiebouwsteen’, i.e. Health and Care Information Model) SOAPReport v1.0 (2020).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | Composition | This is an abstract profile. Child profiles: NlcoreSOAPReport SOAPReport | |
  status | 1..1 | code | preliminary | final | amended | entered-in-error | |
 type | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) 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://snomed.info/sct | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11591000146107 | |
| date | 1..1 | dateTime | SOAPReportDateTime | |
 author | 1..1 | PatternZibHealthProfessionalReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | zib HealthProfessional PractitionerRole) | Author | |
| title | 1..1 | string | Human Readable name/title | |
 Slices for section | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
  section:soapLine | 0..4 | BackboneElement | SOAPLine | |
 code | 1..1 | CodeableConcept | SOAPLineHeader Binding: http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000 (required) | |
| text | 0..1 | Narrative | Text summary of the section, for human interpretation | |
 entry | 1..* | Reference(Resource | zib SOAPReport.SOAPLine) | A reference to data that supports this section | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Composition.section:soapLine.code | required | http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | This is an abstract profile. Child profiles: NlcoreSOAPReport SOAPReport | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
 type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. 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://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11591000146107 | |
| date | Σ | 1..1 | dateTime | SOAPReportDateTime |
| author | Σ | 1..1 | PatternZibHealthProfessionalReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | zib HealthProfessional PractitionerRole) | Author |
| title | Σ | 1..1 | string | Human Readable name/title |
| Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code |
 section:All Slices | Content/Rules for all slices | |||
  modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| section:soapLine | C | 0..4 | BackboneElement | SOAPLine |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | CodeableConcept | SOAPLineHeader Binding: http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000 (required) | |
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
| entry | C | 1..* | Reference(Resource | zib SOAPReport.SOAPLine) | A reference to data that supports this section |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | Pattern: SNOMED CT code 11591000146107 |
| Composition.section:soapLine.code | required | http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000 |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:soapLine | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:soapLine | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | Composition | This is an abstract profile. Child profiles: NlcoreSOAPReport SOAPReport | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11591000146107 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | Σ | 0..1 | Reference(Resource) | Who and/or what the composition is about | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
| date | Σ | 1..1 | dateTime | SOAPReportDateTime | ||||
| author | Σ | 1..1 | PatternZibHealthProfessionalReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | zib HealthProfessional PractitionerRole) | Author | ||||
| title | Σ | 1..1 | string | Human Readable name/title | ||||
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
 target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | ||||
| section:All Slices | Content/Rules for all slices | |||||||
 id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:soapLine | C | 0..4 | BackboneElement | SOAPLine | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | SOAPLineHeader Binding: http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000 (required) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 1..* | Reference(Resource | zib SOAPReport.SOAPLine) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | Pattern: SNOMED CT code 11591000146107 | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:soapLine.code | required | http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000 | ||||
| Composition.section:soapLine.mode | required | ListMode | ||||
| Composition.section:soapLine.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:soapLine.emptyReason | preferred | ListEmptyReasons |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:soapLine | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:soapLine | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 0 element (2 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | This is an abstract profile. Child profiles: NlcoreSOAPReport SOAPReport | |
| status | 1..1 | code | preliminary | final | amended | entered-in-error | |
| type | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) 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://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11591000146107 | |
| date | 1..1 | dateTime | SOAPReportDateTime | |
| author | 1..1 | PatternZibHealthProfessionalReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | zib HealthProfessional PractitionerRole) | Author | |
| title | 1..1 | string | Human Readable name/title | |
| Slices for section | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
| section:soapLine | 0..4 | BackboneElement | SOAPLine | |
| code | 1..1 | CodeableConcept | SOAPLineHeader Binding: http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000 (required) | |
| text | 0..1 | Narrative | Text summary of the section, for human interpretation | |
| entry | 1..* | Reference(Resource | zib SOAPReport.SOAPLine) | A reference to data that supports this section | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Composition.section:soapLine.code | required | http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000 |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | This is an abstract profile. Child profiles: NlcoreSOAPReport SOAPReport | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. 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://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11591000146107 | |
| date | Σ | 1..1 | dateTime | SOAPReportDateTime |
| author | Σ | 1..1 | PatternZibHealthProfessionalReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | zib HealthProfessional PractitionerRole) | Author |
| title | Σ | 1..1 | string | Human Readable name/title |
| Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code |
| section:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| section:soapLine | C | 0..4 | BackboneElement | SOAPLine |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | CodeableConcept | SOAPLineHeader Binding: http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000 (required) | |
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
| entry | C | 1..* | Reference(Resource | zib SOAPReport.SOAPLine) | A reference to data that supports this section |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | Pattern: SNOMED CT code 11591000146107 |
| Composition.section:soapLine.code | required | http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000 |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:soapLine | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:soapLine | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | Composition | This is an abstract profile. Child profiles: NlcoreSOAPReport SOAPReport | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11591000146107 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | Σ | 0..1 | Reference(Resource) | Who and/or what the composition is about | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
| date | Σ | 1..1 | dateTime | SOAPReportDateTime | ||||
| author | Σ | 1..1 | PatternZibHealthProfessionalReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | zib HealthProfessional PractitionerRole) | Author | ||||
| title | Σ | 1..1 | string | Human Readable name/title | ||||
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | ||||
| section:All Slices | Content/Rules for all slices | |||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| section:soapLine | C | 0..4 | BackboneElement | SOAPLine | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 1..1 | CodeableConcept | SOAPLineHeader Binding: http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000 (required) | |||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 1..* | Reference(Resource | zib SOAPReport.SOAPLine) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | Pattern: SNOMED CT code 11591000146107 | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons | ||||
| Composition.section:soapLine.code | required | http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.6.2--20200901000000 | ||||
| Composition.section:soapLine.mode | required | ListMode | ||||
| Composition.section:soapLine.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section:soapLine.emptyReason | preferred | ListEmptyReasons |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:soapLine | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:soapLine | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 0 element (2 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron