diff --git a/input/fsh/profiles/CompositionUvIps.fsh b/input/fsh/profiles/CompositionUvIps.fsh index a6aaafab..4c7f2b6a 100644 --- a/input/fsh/profiles/CompositionUvIps.fsh +++ b/input/fsh/profiles/CompositionUvIps.fsh @@ -67,22 +67,58 @@ The IPS dataset is minimal and non-exhaustive; specialty-agnostic and condition- * section.text 1.. MS * section.section ..0 * section contains - sectionMedications 1..1 MS and - sectionAllergies 1..1 MS and sectionProblems 1..1 MS and - sectionProceduresHx 0..1 MS and + sectionAllergies 1..1 MS and + sectionMedications 1..1 MS and sectionImmunizations 0..1 MS and - sectionMedicalDevices 0..1 MS and sectionResults 0..1 MS and - sectionVitalSigns 0..1 and - sectionPastIllnessHx 0..1 and + sectionProceduresHx 0..1 MS and + sectionMedicalDevices 0..1 MS and + sectionAdvanceDirectives 0..1 and + sectionAlerts 0..1 and sectionFunctionalStatus 0..1 and + sectionPastIllnessHx 0..1 and + sectionPregnancyHx 0..1 and + sectionPatientStory 0..1 and sectionPlanOfCare 0..1 and sectionSocialHistory 0..1 and - sectionPregnancyHx 0..1 and - sectionAdvanceDirectives 0..1 and - sectionAlerts 0..1 and - sectionPatientStory 0..1 + sectionVitalSigns 0..1 +* section[sectionProblems] obeys ips-comp-1 +* section[sectionProblems] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" +* section[sectionProblems] ^extension[=].valueString = "Section" +* section[sectionProblems] ^short = "IPS Problems Section" +* section[sectionProblems] ^definition = "The IPS problem section lists and describes clinical problems or conditions currently being monitored for the patient." +* section[sectionProblems].title 1.. MS +* section[sectionProblems].code 1.. +* section[sectionProblems].code only CodeableConceptIPS +* section[sectionProblems].code = $loinc#11450-4 +* section[sectionProblems].entry only Reference(Condition or DocumentReference) +* section[sectionProblems].entry MS +* section[sectionProblems].entry ^slicing.discriminator[0].type = #profile +* section[sectionProblems].entry ^slicing.discriminator[=].path = "resolve()" +* section[sectionProblems].entry ^slicing.rules = #open +* section[sectionProblems].entry ^short = "Clinical problems or conditions currently being monitored for the patient." +* section[sectionProblems].entry ^definition = "It lists and describes clinical problems or conditions currently being monitored for the patient. This entry shall be used to document that no information about problems is available, or that no relevant problems are known." +* section[sectionProblems].entry contains problem 0..* MS +* section[sectionProblems].entry[problem] only Reference(ConditionUvIps) +* section[sectionAllergies] obeys ips-comp-1 +* section[sectionAllergies] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" +* section[sectionAllergies] ^extension[=].valueString = "Section" +* section[sectionAllergies] ^short = "IPS Allergies and Intolerances Section" +* section[sectionAllergies] ^definition = "This section documents the relevant allergies or intolerances (conditions) for that 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.\r\nAt a minimum, it should list currently active and any relevant historical allergies and adverse reactions.\r\nIf no information about allergies is available, or if no allergies are known this should be clearly documented in the section." +* section[sectionAllergies].title 1.. MS +* section[sectionAllergies].code 1.. +* section[sectionAllergies].code only CodeableConceptIPS +* section[sectionAllergies].code = $loinc#48765-2 +* section[sectionAllergies].entry only Reference(AllergyIntolerance or DocumentReference) +* section[sectionAllergies].entry MS +* section[sectionAllergies].entry ^slicing.discriminator[0].type = #profile +* section[sectionAllergies].entry ^slicing.discriminator[=].path = "resolve()" +* section[sectionAllergies].entry ^slicing.rules = #open +* section[sectionAllergies].entry ^short = "Relevant allergies or intolerances (conditions) for that patient." +* section[sectionAllergies].entry ^definition = "It lists the relevant allergies or intolerances (conditions) for that 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.\r\nAt a minimum, it should list currently active and any relevant historical allergies and adverse reactions.\r\n This entry shall be used to document that no information about allergies is available, or that no allergies are known ." +* section[sectionAllergies].entry contains allergyOrIntolerance 0..* MS +* section[sectionAllergies].entry[allergyOrIntolerance] only Reference(AllergyIntoleranceUvIps) * section[sectionMedications] obeys ips-comp-1 * section[sectionMedications] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" * section[sectionMedications] ^extension[=].valueString = "Section" @@ -106,59 +142,6 @@ The IPS dataset is minimal and non-exhaustive; specialty-agnostic and condition- medicationRequest 0..* * section[sectionMedications].entry[medicationStatement] only Reference(MedicationStatementIPS) * section[sectionMedications].entry[medicationRequest] only Reference(MedicationRequestIPS) -* section[sectionAllergies] obeys ips-comp-1 -* section[sectionAllergies] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" -* section[sectionAllergies] ^extension[=].valueString = "Section" -* section[sectionAllergies] ^short = "IPS Allergies and Intolerances Section" -* section[sectionAllergies] ^definition = "This section documents the relevant allergies or intolerances (conditions) for that 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.\r\nAt a minimum, it should list currently active and any relevant historical allergies and adverse reactions.\r\nIf no information about allergies is available, or if no allergies are known this should be clearly documented in the section." -* section[sectionAllergies].title 1.. MS -* section[sectionAllergies].code 1.. -* section[sectionAllergies].code only CodeableConceptIPS -* section[sectionAllergies].code = $loinc#48765-2 -* section[sectionAllergies].entry only Reference(AllergyIntolerance or DocumentReference) -* section[sectionAllergies].entry MS -* section[sectionAllergies].entry ^slicing.discriminator[0].type = #profile -* section[sectionAllergies].entry ^slicing.discriminator[=].path = "resolve()" -* section[sectionAllergies].entry ^slicing.rules = #open -* section[sectionAllergies].entry ^short = "Relevant allergies or intolerances (conditions) for that patient." -* section[sectionAllergies].entry ^definition = "It lists the relevant allergies or intolerances (conditions) for that 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.\r\nAt a minimum, it should list currently active and any relevant historical allergies and adverse reactions.\r\n This entry shall be used to document that no information about allergies is available, or that no allergies are known ." -* section[sectionAllergies].entry contains allergyOrIntolerance 0..* MS -* section[sectionAllergies].entry[allergyOrIntolerance] only Reference(AllergyIntoleranceUvIps) -* section[sectionProblems] obeys ips-comp-1 -* section[sectionProblems] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" -* section[sectionProblems] ^extension[=].valueString = "Section" -* section[sectionProblems] ^short = "IPS Problems Section" -* section[sectionProblems] ^definition = "The IPS problem section lists and describes clinical problems or conditions currently being monitored for the patient." -* section[sectionProblems].title 1.. MS -* section[sectionProblems].code 1.. -* section[sectionProblems].code only CodeableConceptIPS -* section[sectionProblems].code = $loinc#11450-4 -* section[sectionProblems].entry only Reference(Condition or DocumentReference) -* section[sectionProblems].entry MS -* section[sectionProblems].entry ^slicing.discriminator[0].type = #profile -* section[sectionProblems].entry ^slicing.discriminator[=].path = "resolve()" -* section[sectionProblems].entry ^slicing.rules = #open -* section[sectionProblems].entry ^short = "Clinical problems or conditions currently being monitored for the patient." -* section[sectionProblems].entry ^definition = "It lists and describes clinical problems or conditions currently being monitored for the patient. This entry shall be used to document that no information about problems is available, or that no relevant problems are known." -* section[sectionProblems].entry contains problem 0..* MS -* section[sectionProblems].entry[problem] only Reference(ConditionUvIps) -* section[sectionProceduresHx] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" -* section[sectionProceduresHx] ^extension[=].valueString = "Section" -* section[sectionProceduresHx] ^short = "IPS History of Procedures Section" -* section[sectionProceduresHx] ^definition = "The History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document.\r\nProcedures may refer for example to:\r\n1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)\r\n2. Therapeutic procedure: e.g. dialysis;\r\n3. Surgical procedure: e.g. appendectomy" -* section[sectionProceduresHx].title 1.. MS -* section[sectionProceduresHx].code 1.. -* section[sectionProceduresHx].code only CodeableConceptIPS -* section[sectionProceduresHx].code = $loinc#47519-4 -* section[sectionProceduresHx].entry only Reference(Procedure or DocumentReference) -* section[sectionProceduresHx].entry MS -* section[sectionProceduresHx].entry ^slicing.discriminator[0].type = #profile -* section[sectionProceduresHx].entry ^slicing.discriminator[=].path = "resolve()" -* section[sectionProceduresHx].entry ^slicing.rules = #open -* section[sectionProceduresHx].entry ^short = "Patient past procedures pertinent to the scope of this document." -* section[sectionProceduresHx].entry ^definition = "It lists the patient past procedures that are pertinent to the scope of this document.\r\nProcedures may refer for example to:\r\n1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)\r\n2. Therapeutic procedure: e.g. dialysis;\r\n3. Surgical procedure: e.g. appendectomy. This entry shall be used to document that no information about past procedures is available, or that no relevant past procedures are known." -* section[sectionProceduresHx].entry contains procedure 0..* MS -* section[sectionProceduresHx].entry[procedure] only Reference(ProcedureUvIps) * section[sectionImmunizations] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" * section[sectionImmunizations] ^extension[=].valueString = "Section" * section[sectionImmunizations] ^short = "IPS Immunizations Section" @@ -176,23 +159,6 @@ The IPS dataset is minimal and non-exhaustive; specialty-agnostic and condition- * section[sectionImmunizations].entry ^definition = "It defines the patient's current immunization status and pertinent immunization history.\r\nThe primary use case for the Immunization Section is to enable communication of a patient's immunization status.\r\nIt may contain the entire immunization history that is relevant to the period of time being summarized. This entry shall be used to document that no information about immunizations is available, or that no immunizations are known." * section[sectionImmunizations].entry contains immunization 0..* MS * section[sectionImmunizations].entry[immunization] only Reference(ImmunizationUvIps) -* section[sectionMedicalDevices] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" -* section[sectionMedicalDevices] ^extension[=].valueString = "Section" -* section[sectionMedicalDevices] ^short = "IPS Medical Devices Section" -* section[sectionMedicalDevices] ^definition = "The medical devices section contains narrative text and coded entries describing the patient history of medical device use." -* section[sectionMedicalDevices].title 1.. MS -* section[sectionMedicalDevices].code 1.. -* section[sectionMedicalDevices].code only CodeableConceptIPS -* section[sectionMedicalDevices].code = $loinc#46264-8 -* section[sectionMedicalDevices].entry only Reference(DeviceUseStatement or DocumentReference) -* section[sectionMedicalDevices].entry MS -* section[sectionMedicalDevices].entry ^slicing.discriminator[0].type = #profile -* section[sectionMedicalDevices].entry ^slicing.discriminator[=].path = "resolve()" -* section[sectionMedicalDevices].entry ^slicing.rules = #open -* section[sectionMedicalDevices].entry ^short = "Patient history of medical device use." -* section[sectionMedicalDevices].entry ^definition = "It describes the patient history of medical device use. This entry shall be used to document that no information about medical device use is available, or that no relevant medical device use is known." -* section[sectionMedicalDevices].entry contains deviceStatement 0..* MS -* section[sectionMedicalDevices].entry[deviceStatement] only Reference(DeviceUseStatementUvIps) * section[sectionResults] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" * section[sectionResults] ^extension[=].valueString = "Results Section" * section[sectionResults] ^short = "IPS Results Section" @@ -217,39 +183,72 @@ The IPS dataset is minimal and non-exhaustive; specialty-agnostic and condition- * section[sectionResults].entry[results-observation-laboratory-pathology] only Reference(ObservationResultsLaboratoryPathologyUvIps) * section[sectionResults].entry[results-observation-radiology] only Reference(ObservationResultsRadiologyUvIps) * section[sectionResults].entry[results-diagnosticReport] only Reference(DiagnosticReportUvIps) -* section[sectionVitalSigns] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" -* section[sectionVitalSigns] ^extension[=].valueString = "Vital Signs Section" -* section[sectionVitalSigns] ^label = "Vital signs" -* section[sectionVitalSigns] ^short = "IPS Vital Signs Section" -* section[sectionVitalSigns] ^definition = "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" -* section[sectionVitalSigns].title 1.. -* section[sectionVitalSigns].code 1.. -* section[sectionVitalSigns].code only CodeableConceptIPS -* section[sectionVitalSigns].code = $loinc#8716-3 -* section[sectionVitalSigns].entry only Reference(Observation or DocumentReference) -* section[sectionVitalSigns].entry ^slicing.discriminator[0].type = #profile -* section[sectionVitalSigns].entry ^slicing.discriminator[=].path = "resolve()" -* section[sectionVitalSigns].entry ^slicing.rules = #open -* section[sectionVitalSigns].entry ^short = "Notable vital signs or physical findings." -* section[sectionVitalSigns].entry ^definition = "Notable vital signs or physical findings as: blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included" -* section[sectionVitalSigns].entry contains vitalSign 0..* -* section[sectionVitalSigns].entry[vitalSign] only Reference($vitalsigns) -* section[sectionPastIllnessHx] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" -* section[sectionPastIllnessHx] ^extension[=].valueString = "Section" -* section[sectionPastIllnessHx] ^short = "IPS History of Past Illness Section" -* section[sectionPastIllnessHx] ^definition = "The History of Past Illness section contains a description of the conditions the patient suffered in the past." -* section[sectionPastIllnessHx].title 1.. -* section[sectionPastIllnessHx].code 1.. -* section[sectionPastIllnessHx].code only CodeableConceptIPS -* section[sectionPastIllnessHx].code = $loinc#11348-0 -* section[sectionPastIllnessHx].entry only Reference(Condition or DocumentReference) -* section[sectionPastIllnessHx].entry ^slicing.discriminator[0].type = #profile -* section[sectionPastIllnessHx].entry ^slicing.discriminator[=].path = "resolve()" -* section[sectionPastIllnessHx].entry ^slicing.rules = #open -* section[sectionPastIllnessHx].entry ^short = "Conditions the patient suffered in the past." -* section[sectionPastIllnessHx].entry ^definition = "It contains a description of the conditions the patient suffered in the past." -* section[sectionPastIllnessHx].entry contains pastProblem 0..* -* section[sectionPastIllnessHx].entry[pastProblem] only Reference(ConditionUvIps) +* section[sectionProceduresHx] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" +* section[sectionProceduresHx] ^extension[=].valueString = "Section" +* section[sectionProceduresHx] ^short = "IPS History of Procedures Section" +* section[sectionProceduresHx] ^definition = "The History of Procedures Section contains a description of the patient past procedures that are pertinent to the scope of this document.\r\nProcedures may refer for example to:\r\n1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)\r\n2. Therapeutic procedure: e.g. dialysis;\r\n3. Surgical procedure: e.g. appendectomy" +* section[sectionProceduresHx].title 1.. MS +* section[sectionProceduresHx].code 1.. +* section[sectionProceduresHx].code only CodeableConceptIPS +* section[sectionProceduresHx].code = $loinc#47519-4 +* section[sectionProceduresHx].entry only Reference(Procedure or DocumentReference) +* section[sectionProceduresHx].entry MS +* section[sectionProceduresHx].entry ^slicing.discriminator[0].type = #profile +* section[sectionProceduresHx].entry ^slicing.discriminator[=].path = "resolve()" +* section[sectionProceduresHx].entry ^slicing.rules = #open +* section[sectionProceduresHx].entry ^short = "Patient past procedures pertinent to the scope of this document." +* section[sectionProceduresHx].entry ^definition = "It lists the patient past procedures that are pertinent to the scope of this document.\r\nProcedures may refer for example to:\r\n1. Invasive Diagnostic procedure:e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)\r\n2. Therapeutic procedure: e.g. dialysis;\r\n3. Surgical procedure: e.g. appendectomy. This entry shall be used to document that no information about past procedures is available, or that no relevant past procedures are known." +* section[sectionProceduresHx].entry contains procedure 0..* MS +* section[sectionProceduresHx].entry[procedure] only Reference(ProcedureUvIps) +* section[sectionMedicalDevices] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" +* section[sectionMedicalDevices] ^extension[=].valueString = "Section" +* section[sectionMedicalDevices] ^short = "IPS Medical Devices Section" +* section[sectionMedicalDevices] ^definition = "The medical devices section contains narrative text and coded entries describing the patient history of medical device use." +* section[sectionMedicalDevices].title 1.. MS +* section[sectionMedicalDevices].code 1.. +* section[sectionMedicalDevices].code only CodeableConceptIPS +* section[sectionMedicalDevices].code = $loinc#46264-8 +* section[sectionMedicalDevices].entry only Reference(DeviceUseStatement or DocumentReference) +* section[sectionMedicalDevices].entry MS +* section[sectionMedicalDevices].entry ^slicing.discriminator[0].type = #profile +* section[sectionMedicalDevices].entry ^slicing.discriminator[=].path = "resolve()" +* section[sectionMedicalDevices].entry ^slicing.rules = #open +* section[sectionMedicalDevices].entry ^short = "Patient history of medical device use." +* section[sectionMedicalDevices].entry ^definition = "It describes the patient history of medical device use. This entry shall be used to document that no information about medical device use is available, or that no relevant medical device use is known." +* section[sectionMedicalDevices].entry contains deviceStatement 0..* MS +* section[sectionMedicalDevices].entry[deviceStatement] only Reference(DeviceUseStatementUvIps) +* section[sectionAdvanceDirectives] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" +* section[sectionAdvanceDirectives] ^extension[=].valueString = "Section" +* section[sectionAdvanceDirectives] ^short = "IPS Advance Directives Section" +* section[sectionAdvanceDirectives] ^definition = "The advance directives section contains a narrative description of patient's advance directive." +* section[sectionAdvanceDirectives].title 1.. +* section[sectionAdvanceDirectives].code 1.. +* section[sectionAdvanceDirectives].code only CodeableConceptIPS +* section[sectionAdvanceDirectives].code = $loinc#42348-3 +* section[sectionAdvanceDirectives].entry only Reference(Consent or DocumentReference) +* section[sectionAdvanceDirectives].entry ^slicing.discriminator[0].type = #profile +* section[sectionAdvanceDirectives].entry ^slicing.discriminator[=].path = "resolve()" +* section[sectionAdvanceDirectives].entry ^slicing.rules = #open +* section[sectionAdvanceDirectives].entry ^short = "Narrative description of the patient's advance directive." +* section[sectionAdvanceDirectives].entry ^definition = "Contains a narrative description or a Consent entry with information about the patient's advance directive." +* section[sectionAdvanceDirectives].entry contains advanceDirectivesConsent 0..* +* section[sectionAdvanceDirectives].entry[advanceDirectivesConsent] only Reference(Consent) +* section[sectionAlerts] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" +* section[sectionAlerts] ^extension[=].valueString = "Section" +* section[sectionAlerts] ^short = "IPS Alerts Section" +* section[sectionAlerts] ^definition = "The alerts section flags potential concerns and/or dangers to/from the patient and may also include obstacles to care." +* section[sectionAlerts].title 1.. +* section[sectionAlerts].code 1.. +* section[sectionAlerts].code only CodeableConceptIPS +* section[sectionAlerts].code = $loinc#104605-1 +* section[sectionAlerts].entry only Reference(Flag or DocumentReference) +* section[sectionAlerts].entry ^slicing.discriminator[0].type = #profile +* section[sectionAlerts].entry ^slicing.discriminator[=].path = "resolve()" +* section[sectionAlerts].entry ^slicing.rules = #open +* section[sectionAlerts].entry ^short = "Alert information." +* section[sectionAlerts].entry ^definition = "Contains alert information to be communicated. May optionally reference other resources in IPS." +* section[sectionAlerts].entry contains alertsFlag 0..* +* section[sectionAlerts].entry[alertsFlag] only Reference(FlagAlertUvIps) * section[sectionFunctionalStatus] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" * section[sectionFunctionalStatus] ^extension[=].valueString = "Section" * section[sectionFunctionalStatus] ^short = "IPS Functional Status" @@ -269,6 +268,52 @@ The IPS dataset is minimal and non-exhaustive; specialty-agnostic and condition- functionalAssessment 0..* * section[sectionFunctionalStatus].entry[disability] only Reference(ConditionUvIps) * section[sectionFunctionalStatus].entry[functionalAssessment] only Reference(ClinicalImpression) +* section[sectionPastIllnessHx] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" +* section[sectionPastIllnessHx] ^extension[=].valueString = "Section" +* section[sectionPastIllnessHx] ^short = "IPS History of Past Illness Section" +* section[sectionPastIllnessHx] ^definition = "The History of Past Illness section contains a description of the conditions the patient suffered in the past." +* section[sectionPastIllnessHx].title 1.. +* section[sectionPastIllnessHx].code 1.. +* section[sectionPastIllnessHx].code only CodeableConceptIPS +* section[sectionPastIllnessHx].code = $loinc#11348-0 +* section[sectionPastIllnessHx].entry only Reference(Condition or DocumentReference) +* section[sectionPastIllnessHx].entry ^slicing.discriminator[0].type = #profile +* section[sectionPastIllnessHx].entry ^slicing.discriminator[=].path = "resolve()" +* section[sectionPastIllnessHx].entry ^slicing.rules = #open +* section[sectionPastIllnessHx].entry ^short = "Conditions the patient suffered in the past." +* section[sectionPastIllnessHx].entry ^definition = "It contains a description of the conditions the patient suffered in the past." +* section[sectionPastIllnessHx].entry contains pastProblem 0..* +* section[sectionPastIllnessHx].entry[pastProblem] only Reference(ConditionUvIps) +* section[sectionPregnancyHx] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" +* section[sectionPregnancyHx] ^extension[=].valueString = "Section" +* section[sectionPregnancyHx] ^short = "IPS History of Pregnancy Section" +* section[sectionPregnancyHx] ^definition = "The history of pregnancy section shall contain information about whether the patient is currently pregnant or not.\r\nIt may contain addition summarizing information about the outcome of earlier pregnancies." +* section[sectionPregnancyHx].title 1.. +* section[sectionPregnancyHx].code 1.. +* section[sectionPregnancyHx].code only CodeableConceptIPS +* section[sectionPregnancyHx].code = $loinc#10162-6 +* section[sectionPregnancyHx].entry only Reference(Observation or DocumentReference) +* section[sectionPregnancyHx].entry ^slicing.discriminator[0].type = #profile +* section[sectionPregnancyHx].entry ^slicing.discriminator[=].path = "resolve()" +* section[sectionPregnancyHx].entry ^slicing.rules = #open +* section[sectionPregnancyHx].entry ^short = "Current pregnancy status and, optionally, information about the outcome of earlier pregnancies." +* section[sectionPregnancyHx].entry ^definition = "It contains information about whether the patient is currently pregnant or not.\r\nIt may contain addition summarizing information about the outcome of earlier pregnancies." +* section[sectionPregnancyHx].entry contains + pregnancyStatus 0..* and + pregnancyOutcome 0..* +* section[sectionPregnancyHx].entry[pregnancyStatus] only Reference(ObservationPregnancyStatusUvIps) +* section[sectionPregnancyHx].entry[pregnancyOutcome] only Reference(ObservationPregnancyOutcomeUvIps) + +* section[sectionPatientStory] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" +* section[sectionPatientStory] ^extension[=].valueString = "Section" +* section[sectionPatientStory] ^short = "IPS Patient Story Section" +* section[sectionPatientStory] ^definition = "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. The patient’s story, provided here, may be told by the patient or by a proxy." +* section[sectionPatientStory].title 1.. +* section[sectionPatientStory].code 1.. +* section[sectionPatientStory].code only CodeableConceptIPS +* section[sectionPatientStory].code = $loinc#81338-6 +* section[sectionPatientStory].entry ^short = "Patient Story resources." +* section[sectionPatientStory].entry ^definition = "Contains resources to support the Patient Story. Instances of DocumentReference or any other suitable resource type may be used." * section[sectionPlanOfCare] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" * section[sectionPlanOfCare] ^extension[=].valueString = "Section" * section[sectionPlanOfCare] ^short = "IPS Plan of Care Section" @@ -304,64 +349,20 @@ The IPS dataset is minimal and non-exhaustive; specialty-agnostic and condition- alcoholUse 0..1 * section[sectionSocialHistory].entry[smokingTobaccoUse] only Reference(ObservationTobaccoUseUvIps) * section[sectionSocialHistory].entry[alcoholUse] only Reference(ObservationAlcoholUseUvIps) -* section[sectionPregnancyHx] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" -* section[sectionPregnancyHx] ^extension[=].valueString = "Section" -* section[sectionPregnancyHx] ^short = "IPS History of Pregnancy Section" -* section[sectionPregnancyHx] ^definition = "The history of pregnancy section shall contain information about whether the patient is currently pregnant or not.\r\nIt may contain addition summarizing information about the outcome of earlier pregnancies." -* section[sectionPregnancyHx].title 1.. -* section[sectionPregnancyHx].code 1.. -* section[sectionPregnancyHx].code only CodeableConceptIPS -* section[sectionPregnancyHx].code = $loinc#10162-6 -* section[sectionPregnancyHx].entry only Reference(Observation or DocumentReference) -* section[sectionPregnancyHx].entry ^slicing.discriminator[0].type = #profile -* section[sectionPregnancyHx].entry ^slicing.discriminator[=].path = "resolve()" -* section[sectionPregnancyHx].entry ^slicing.rules = #open -* section[sectionPregnancyHx].entry ^short = "Current pregnancy status and, optionally, information about the outcome of earlier pregnancies." -* section[sectionPregnancyHx].entry ^definition = "It contains information about whether the patient is currently pregnant or not.\r\nIt may contain addition summarizing information about the outcome of earlier pregnancies." -* section[sectionPregnancyHx].entry contains - pregnancyStatus 0..* and - pregnancyOutcome 0..* -* section[sectionPregnancyHx].entry[pregnancyStatus] only Reference(ObservationPregnancyStatusUvIps) -* section[sectionPregnancyHx].entry[pregnancyOutcome] only Reference(ObservationPregnancyOutcomeUvIps) -* section[sectionAdvanceDirectives] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" -* section[sectionAdvanceDirectives] ^extension[=].valueString = "Section" -* section[sectionAdvanceDirectives] ^short = "IPS Advance Directives Section" -* section[sectionAdvanceDirectives] ^definition = "The advance directives section contains a narrative description of patient's advance directive." -* section[sectionAdvanceDirectives].title 1.. -* section[sectionAdvanceDirectives].code 1.. -* section[sectionAdvanceDirectives].code only CodeableConceptIPS -* section[sectionAdvanceDirectives].code = $loinc#42348-3 -* section[sectionAdvanceDirectives].entry only Reference(Consent or DocumentReference) -* section[sectionAdvanceDirectives].entry ^slicing.discriminator[0].type = #profile -* section[sectionAdvanceDirectives].entry ^slicing.discriminator[=].path = "resolve()" -* section[sectionAdvanceDirectives].entry ^slicing.rules = #open -* section[sectionAdvanceDirectives].entry ^short = "Narrative description of the patient's advance directive." -* section[sectionAdvanceDirectives].entry ^definition = "Contains a narrative description or a Consent entry with information about the patient's advance directive." -* section[sectionAdvanceDirectives].entry contains advanceDirectivesConsent 0..* -* section[sectionAdvanceDirectives].entry[advanceDirectivesConsent] only Reference(Consent) -* section[sectionAlerts] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" -* section[sectionAlerts] ^extension[=].valueString = "Section" -* section[sectionAlerts] ^short = "IPS Alerts Section" -* section[sectionAlerts] ^definition = "The alerts section flags potential concerns and/or dangers to/from the patient and may also include obstacles to care." -* section[sectionAlerts].title 1.. -* section[sectionAlerts].code 1.. -* section[sectionAlerts].code only CodeableConceptIPS -* section[sectionAlerts].code = $loinc#104605-1 -* section[sectionAlerts].entry only Reference(Flag or DocumentReference) -* section[sectionAlerts].entry ^slicing.discriminator[0].type = #profile -* section[sectionAlerts].entry ^slicing.discriminator[=].path = "resolve()" -* section[sectionAlerts].entry ^slicing.rules = #open -* section[sectionAlerts].entry ^short = "Alert information." -* section[sectionAlerts].entry ^definition = "Contains alert information to be communicated. May optionally reference other resources in IPS." -* section[sectionAlerts].entry contains alertsFlag 0..* -* section[sectionAlerts].entry[alertsFlag] only Reference(FlagAlertUvIps) -* section[sectionPatientStory] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" -* section[sectionPatientStory] ^extension[=].valueString = "Section" -* section[sectionPatientStory] ^short = "IPS Patient Story Section" -* section[sectionPatientStory] ^definition = "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. The patient’s story, provided here, may be told by the patient or by a proxy." -* section[sectionPatientStory].title 1.. -* section[sectionPatientStory].code 1.. -* section[sectionPatientStory].code only CodeableConceptIPS -* section[sectionPatientStory].code = $loinc#81338-6 -* section[sectionPatientStory].entry ^short = "Patient Story resources." -* section[sectionPatientStory].entry ^definition = "Contains resources to support the Patient Story. Instances of DocumentReference or any other suitable resource type may be used." \ No newline at end of file +* section[sectionVitalSigns] ^extension[0].url = "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name" +* section[sectionVitalSigns] ^extension[=].valueString = "Vital Signs Section" +* section[sectionVitalSigns] ^label = "Vital signs" +* section[sectionVitalSigns] ^short = "IPS Vital Signs Section" +* section[sectionVitalSigns] ^definition = "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" +* section[sectionVitalSigns].title 1.. +* section[sectionVitalSigns].code 1.. +* section[sectionVitalSigns].code only CodeableConceptIPS +* section[sectionVitalSigns].code = $loinc#8716-3 +* section[sectionVitalSigns].entry only Reference(Observation or DocumentReference) +* section[sectionVitalSigns].entry ^slicing.discriminator[0].type = #profile +* section[sectionVitalSigns].entry ^slicing.discriminator[=].path = "resolve()" +* section[sectionVitalSigns].entry ^slicing.rules = #open +* section[sectionVitalSigns].entry ^short = "Notable vital signs or physical findings." +* section[sectionVitalSigns].entry ^definition = "Notable vital signs or physical findings as: blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included" +* section[sectionVitalSigns].entry contains vitalSign 0..* +* section[sectionVitalSigns].entry[vitalSign] only Reference($vitalsigns) \ No newline at end of file diff --git a/input/images/IPS_composition.png b/input/images/IPS_composition.png index a3452895..833f48b4 100644 Binary files a/input/images/IPS_composition.png and b/input/images/IPS_composition.png differ diff --git a/input/images/IPS_doc_library.png b/input/images/IPS_doc_library.png index b6db25cd..eeea5673 100644 Binary files a/input/images/IPS_doc_library.png and b/input/images/IPS_doc_library.png differ diff --git a/input/pagecontent/Structure-of-the-International-Patient-Summary.md b/input/pagecontent/Structure-of-the-International-Patient-Summary.md index ca96328f..b6c522b7 100644 --- a/input/pagecontent/Structure-of-the-International-Patient-Summary.md +++ b/input/pagecontent/Structure-of-the-International-Patient-Summary.md @@ -4,6 +4,16 @@ The IPS is composed by the following sections described below. ### Sections description +#### Problem List + +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). + +#### 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 documented in the section through the use of emptyReason (at Composition.section) or a referenced resource (at Composition.section.entry). + #### Medication Summary The medication summary section contains a description of the patient's medications relevant for the scope of the patient summary. @@ -22,19 +32,18 @@ Populating this section must be one of the choices below: - 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. +#### Immunizations -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). +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. -#### Problem List +#### Diagnostic Results -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). +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. -#### Immunizations +This section includes entry choices to carry result observations (using Observation or referenced observations in DiagnosticReport) from: -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. +- Laboratory/pathology +- Radiology #### History of Procedures @@ -50,56 +59,47 @@ 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 +#### Advance Directives -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. +The advance directives section contains a narrative description of patient's advance directives with links to supporting documents and consents. -This section includes entry choices to carry result observations (using Observation or referenced observations in DiagnosticReport) from: +#### Alerts -- Laboratory/pathology -- Radiology +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. -#### Vital Signs +#### Functional Status -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 +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. -#### Past history of illnesses +#### History of Past Problems The History of Past Illness section contains a description of the conditions the patient suffered in the past. -#### Pregnancy (status and history summary) +#### History of 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) -#### Social History - -The social history is comprised of +#### Patient Story -- Tobacco use -- Alcohol use +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. #### 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 may be specified by future versions of this guide. - -#### Advance Directives - -The advance directives section contains a narrative description of patient's advance directives with links to supporting documents and consents. +#### Social History -### Alerts +The social history is comprised of -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. +- Tobacco use +- Alcohol use -### Patient Story +#### Vital Signs -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. +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 ### List of Profiles @@ -107,22 +107,16 @@ The profiles that have been defined for this implementation guide are listed Condition (IPS) ] +- Allergies and Intolerances (R) + [ Allergy Intolerance (IPS) ] - Medication Summary (R) [ Medication Statement (IPS) | Medication Request (IPS) | Medication (IPS) ] -- Allergies and Intolerances (R) - [ Allergy Intolerance (IPS) ] -- Problem List (R) - [ Condition (IPS) ] - Immunizations (S) [ Immunization (IPS) ] -- History of Procedures (S) - [ Procedure (IPS) | - Device (performer, observer) ] -- Medical Devices (S) - [ Device Use Statement (IPS) | - Device (IPS) ] - Diagnostic Results (S) [ DiagnosticReport (IPS) ] - Laboratory/Pathology results @@ -132,28 +126,34 @@ Following are the profiles that have been defined for each section. (R) denotes [ Observation Results: radiology (IPS) | Device (performer, observer) | Imaging Study (IPS) ] -- Vital Signs - [ Vital Signs Profiles ] -- Past history of illnesses +- History of Procedures (S) + [ Procedure (IPS) | + Device (performer, observer) ] +- Medical Devices (S) + [ Device Use Statement (IPS) | + Device (IPS) ] +- Advance Directives + [ Consent ] +- Alerts + [ Flag - Alert (IPS) ] +- Functional Status (Autonomy / Invalidity) + [ Condition (IPS) | + Clinical Impression ] +- History of Past Problems [ Condition (IPS) ] -- Pregnancy (status and history summary) +- History of Pregnancy (status and history summary) [ Observation (Pregnancy: EDD) | Observation (Pregnancy: outcome) | Observation (Pregnancy: status) ] +- Patient Story + [ No specific resources required. Any may be used to support narrative. ] +- Plan of care + [ Care Plan ] - Social History [ Observation (SH: tobacco use) | Observation (SH: alcohol use) ] -- Functional Status (Autonomy / Invalidity) - [ Condition (IPS) | - Clinical Impression ] -- Plan of care - [ Care Plan ] -- Advance Directives - [ Consent ] -- Alerts - [ Flag - Alert (IPS) ] -- Patient Story - [ No specific resources required. Any may be used to support narrative. ] +- Vital Signs + [ Vital Signs Profiles ] - Resources and profiles used across various sections [ Organization (IPS) | Practitioner (IPS) | PractitionerRole (IPS) | DocumentReference]