FHIR-41556 plus cleanup for new sections

input/pagecontent/ipsStructure.md

@@ -8,38 +8,33 @@ The IPS is composed by the following sections described below.
 
 #### Medication Summary
 
-
 The medication summary section contains a description of the patient's medications relevant for the scope of the patient summary.
 
 The actual content could depend on the jurisdiction, it could report:
-- the currently active medications;
-- the current and past medications considered relevant by the authoring GP;
-- the patient prescriptions or dispensations automatically extracted by a regional or a national EHR.
-
-In all those cases however medications are documented in the Patient Summary as medication statements.
+- The currently active medications
+- The current and past medications considered relevant by the authoring practitioner
+- The patient prescriptions or dispensations automatically extracted by a regional or a national EHR
 
-The entries of this section must be one of the choices below:
-- an entry stating that the patient is known not to be under any relevant medication;
-- an entry stating that no information is available about the patient's potential medications;
-- one or more entries enumerating the patient's relevant medication (one entry per medication).
+In all those cases however medications are documented in the Patient Summary as medication statements or medication requests.
 
+Populating this section must be one of the choices below:
+- No entry with use of emptyReason (at Composition.section)
+- An entry stating that the patient is known not to be under any relevant medication (or other "no medication information")
+- One or more entries enumerating the patient's relevant medication (one entry per medication)
 
 #### Allergies and Intolerances
 
 This section documents the relevant allergies or intolerances (conditions) for a patient, describing the kind of reaction (e.g. rash, anaphylaxis,..); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy.
-At a minimum, it should list currently active and any relevant historical allergies and adverse reactions.
-If no information about allergies is available, or if no allergies are known this should be clearly documented in the section.
 
+At a minimum, it should list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this should be  documented in the section through the use of emptyReason (at Composition.section) or a referenced resource (at Composition.section.entry).
 
 #### Problem List
 
-The IPS problem section lists and describes clinical problems or conditions currently being monitored for the patient.
+The IPS problem section lists and describes clinical problems or conditions currently being monitored for the patient. If no information about problems is available or there are no known problems, this documented in the section through the use of emptyReason (at Composition.section) or a referenced resource (at Composition.section.entry).
 
 #### Immunizations
 
-The Immunizations Section defines a patient's current immunization status and pertinent immunization history.
-The primary use case for the Immunization Section is to enable communication of a patient's immunization status.
-The section includes current immunization status and the entire clinically pertinent immunization history that is known.
+The Immunizations Section defines a patient's current immunization status and pertinent immunization history.The primary use case for the Immunization Section is to enable communication of a patient's immunization status.The section includes current immunization status and the entire clinically pertinent immunization history that is known.
 
 #### History of Procedures
 
@@ -54,39 +49,42 @@ Procedures may refer for example to:
 The medical devices section contains narrative text and coded entries describing the patient history of medical device use.
 
 #### Diagnostic Results
-This section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results may be laboratory results, others may be anatomic pathology results, and others, radiology results.
+This section assembles relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. These results may include laboratory, pathology, and radiology results.
 
 This section includes entry choices to carry result observations (using Observation or referenced observations in DiagnosticReport) from:
-* laboratory/pathology
-* radiology
-
-A generic result entry is also supported.
+* Laboratory/pathology
+* Radiology
 
 #### Vital Signs
 The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included
 
 #### Past history of illnesses
-The History of Past Illness section contains a description of the conditions the patient suffered in the past
+The History of Past Illness section contains a description of the conditions the patient suffered in the past.
 
 #### Pregnancy (status and history summary)
 The pregnancy status and history is comprised of 
-* an entry as an Observation of the pregnancy status, and optionally, a member Observation of the Estimated Delivery Date
-* an entry as an Observation of the pregnancy history (summary)
+* An entry as an Observation of the pregnancy status, and optionally, a member Observation of the Estimated Delivery Date
+* An entry as an Observation of the pregnancy history (summary)
 
 #### Social History
-The social history is as of now comprised of 
-* tobacco use
-* alcohol use
+The social history is comprised of 
+* Tobacco use
+* Alcohol use
 
 #### Plan of Care
 The plan of care section contains a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.
 
 #### Functional Status
-The functional status section contains a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments.
-Profiles to express disabilities and functional assessments will be specified by future versions of this guide.
+The functional status section contains a narrative description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status may in fact influence decisions about how to administer treatments. Profiles to express disabilities and functional assessments may be specified by future versions of this guide.
 
 #### Advance Directives
-The advance directives section contains a narrative description of patient's advance directives.
+The advance directives section contains a narrative description of patient's advance directives with links to supporting documents and consents.
+
+### Alerts 
+This alerts section is used to convey information flagged to raise awareness of potential concerns and/or dangers to/from the subject of the IPS.
+
+### Patient Story
+The section contains narrative text along with optional resources that express what matters to a patient. This may include needs, strengths, values, concerns and preferences to others providing support and care. Any resource type may be used to support narrative.  
 
 ### List of Profiles
 
@@ -131,7 +129,7 @@ Following are the profiles that have been defined for each section. (R) denotes
  <a href="StructureDefinition-Observation-pregnancy-outcome-uv-ips.html">Observation (Pregnancy: outcome)</a> |
  <a href="StructureDefinition-Observation-pregnancy-status-uv-ips.html">Observation (Pregnancy: status)</a> ]
 * Social History
- [ <a href="StructureDefinition-Observation-alcoholuse-uv-ips.html">Observation (SH: alcohol use)</a> |
+  [ <a href="{{site.data.fhir.path}}careplan.html">Care Plan</a> ]
  <a href="StructureDefinition-Observation-tobaccouse-uv-ips.html">Observation (SH: tobacco use)</a> ]
 * Functional Status (Autonomy / Invalidity)
  [ <a href="StructureDefinition-Condition-uv-ips.html">Condition (IPS)</a> |
@@ -140,5 +138,8 @@ Following are the profiles that have been defined for each section. (R) denotes
   [ <a href="{{site.data.fhir.path}}careplan.html">Care Plan</a> ]
 * Advance Directives
   [ <a href="{{site.data.fhir.path}}consent.html">Consent</a> ]
-
+* Alerts
+ [ <a href="StructureDefinition-Flag-alert-uv-ips.html">Flag - Alert (IPS)</a> ]
+* Patient Story
+ [ No specific resources required. Any may be used to support narrative. ]
 ---