SWISS.MEDNET.FHIR\MedNet Interface (MNI) - PatientOverview Composition

The id is unique within the space of all resources of the same type on the same server It can be any combination of upper- or lower-case ASCII letters 'A'..'Z', and 'a'..'z', numerals ('0'..'9'), '-' and '.' with a length limit of 64 characters. (This might be an integer, an un-prefixed OID, UUID or any other identifier pattern that meets these constraints.)

category

0..*

Reference(MedNet Interface (MNI) - Patient)

Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.

subject

SΣ

1..1

Link to the Patient

encounter

SΣ

0..1

Reference(MedNet Interface (MNI) - Encounter)

An encounter will provide information about the context in which the form will be filled It is mainly used to deliver MedNet the Visit Nr (or Case Nr), and/or the orderNr from the calling System. The goal of those values is to allow saving the copy of the form and/or the later resulting report in the calling system to an internal event. It can also include informations about the priority of the request (if it is urgent or not), or the type of form that should be filled.

date

SΣ

1..1

dateTime

Composition editing time

Reference(MedNet Interface (MNI) - Device | MedNet Interface (MNI) - SoftwareUser)

SΣ

1..*

Who and/or what authored the composition

SΣ

1..1

Human Readable name/title
Fixed Value: PatientOverview

confidentiality

SΣ

1..1

N = normal
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

Fixed Value: N

attester

0..*

Attests to accuracy of composition

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

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

0..1

Reference(Organization)

Organization which maintains the composition

relatesTo

0..*

Relationships to other compositions/documents

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

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

0..*

The clinical service(s) being documented

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

0..*

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

0..1

Period

The period covered by the documentation

detail

0..*

The event(s) being documented

Slices for section

0..*

Composition is broken into sections
Slice: Unordered, Open by pattern:$this.code

section:All Slices

Content/Rules for all slices

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

0..1

Label for section (e.g. for ToC)

0..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

entry

0..*

A reference to data that supports this section

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

Nested Section

section:insuranceData

0..1

This section will provide patient insurance information

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Insurance data section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 76437-3

1..1

Representation defined by the system
Fixed Value: Primary insurance

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

Reference(MedNet Interface (MNI) - Coverage) {b }

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

entry:Coverage

1..*

The coverage objects that will include all the informations about the insurances and invoices management

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

section:sectionMedications

Nested Section

0..1

This section will provide all the Medication taken by the patient

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Medication Summary section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 10160-0

1..1

Representation defined by the system
Fixed Value: History of Medication use Narrative

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

entry:medicationStatement

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

1..*

Reference(MedNet Interface (MNI) - Medication Statement) {b }

A record of a medication that is being consumed by a patient

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

Nested Section

section:sectionAllergies

0..1

This section will provide detailed information about allergies or intolerances of the patient (generally: Risk of adverse reaction to a substance)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Allergies section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 48765-2

1..1

Representation defined by the system
Fixed Value: Allergies and adverse reactions Document

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

entry:allergyOrIntolerance

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

1..*

Reference(MedNet Interface (MNI) - Allergy Intolerance) {b }

An allergy or intolerance record

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

Nested Section

section:sectionProblems

0..1

This section will provide detailed information about conditions, problems or diagnoses (German = Diagnose, French = Diagnostics)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Problems section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 11450-4

1..1

Representation defined by the system
Fixed Value: Problem list - Reported

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

Reference(MedNet Interface (MNI) - Condition) {b }

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

entry:problem

1..*

A problem record

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

section:sectionProceduresHx

Nested Section

0..1

This section will provide detailed information about actions that are or were performed on or for a patient. This can be physical interventions like an operations, or less invasive like long term services, counseling, or hypnotherapy. (German = Massnahme, French = Intervention)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Procedures section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 47519-4

1..1

Representation defined by the system
Fixed Value: History of Procedures Document

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

Reference(MedNet Interface (MNI) - Procedure) {b }

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

entry:procedure

1..*

A procedure record

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

Nested Section

section:sectionResults

0..1

This section will provide some relevant laboratory observations

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Results section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 30954-2

1..1

Representation defined by the system
Fixed Value: Relevant diagnostic tests/laboratory data Narrative

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

entry:results-observation

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

1..*

Reference(MedNet Interface (MNI) - Laboratory Observation) {b }

Laboratory Observation

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

section:sectionVitalSigns

Nested Section

0..1

This section will provide detailed information about patient vital signs

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Vital signs section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 8716-3

1..1

Representation defined by the system
Fixed Value: Vital signs

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

Reference(MedNet Interface (MNI) - Body Weight) {b }

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

entry:bodyWeight

0..1

Body Weight of the patient

entry:bodyHeight

0..1

Reference(MedNet Interface (MNI) - Body Height) {b }

Bodyheight of the patient

entry:bodyMassIndex

0..1

Reference(MedNet Interface (MNI) - Body Mass Index) {b }

Body Mass Index of the patient

entry:bloodPressure

0..1

Reference(MedNet Interface (MNI) - Blood Pressure) {b }

Blood pressure of the patient

entry:bloodGroup

0..1

Reference(MedNet Interface (MNI) - Blood Group) {b }

Blood group of the patient

entry:dateOfLastMenstruation

0..1

Reference(MedNet Interface (MNI) - First day of last menstruation) {b }

Date of last menstruation (German = Ersten Tag der letzte Monatsblutung, French = Premier jour des dernières règles)

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

section:sectionSocialHistory

Nested Section

0..1

This section will provide detailed information potential outcomes and family members cases

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Social history section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 29762-2

1..1

Representation defined by the system
Fixed Value: Social history Narrative

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

Reference(MedNet Interface (MNI) - Risk Factor) {b }

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

entry:riskFactors

0..*

Potential outcomes for a subject with likelihood (CAVE). (German = Risiko Factor , French = Facteur de risque )

entry:familyMemberHistory

0..*

Reference(MedNet Interface (MNI) - Family Member History) {b }

Information about patient's relatives, relevant for patient. (German = Familienanamnese, French = Anamnèse familiale

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

section:sectionPregnancyHx

Nested Section

0..1

This section will provide medical informations dedicated to pregnancy. This section must be delivered only if the patient is Pregnant.

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Pregnancy section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 10162-6

1..1

Representation defined by the system
Fixed Value: History of pregnancies Narrative

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

0..*

entry:estimatedDateOfConception

A reference to pregnancy information. If no entry is specified, but the section exists, it means that the Patient is pregnant but no additional informations are available
Slice: Unordered, Open by profile:resolve()

0..1

Reference(MedNet Interface (MNI) - Estimated date of conception) {b }

Estimated date of conception (German = Geschätzte Konzeptions Datum, French = Date de conception estimée)

entry:estimatedDateOfDelivery

0..1

Reference(MedNet Interface (MNI) - Estimated date of delivery) {b }

Estimated date of delivery (German = Geplante Geburts Datum, French = Date d'accouchement prévue)

entry:dateOfLastMenstruation

0..1

Reference(MedNet Interface (MNI) - First day of last menstruation) {b }

Date of last menstruation (German = Ersten Tag der letzte Monatsblutung, French = Premier jour des dernières règles)

entry:timeOfGestation

0..1

Reference(MedNet Interface (MNI) - Time of gestation) {b }

Time of gestation (German = Tage/Woche seit Schwangerschaft Beginn / Schwangerschaftswoche / SSW, French = Nombre de jour/semaine depuis le début de la grossesse)

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

Nested Section

section:annotations

0..1

This section will provide information that can not be structured in the previous sections but that can be usefull for filling a form.

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Comment

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://loinc.org

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: 48767-8

1..1

Representation defined by the system
Fixed Value: Annotation comment [Interpretation] Narrative

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..*

Who and/or what authored the section

0..1

Who/what the section is about, when it is not about the subject of composition

0..1

Text summary of the section, for human interpretation

0..1

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

0..1

Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

1..*

Reference(MedNet Interface (MNI) - Annotation Observation) {b }

A reference to data that supports this section
Slice: Unordered, Open by profile:resolve()

entry:observation

1..*

An annotation observation record

0..1

Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

0..*

Nested Section

section:documents

0..1

This section will provide relevant documents

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

?!Σ

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Label for section (e.g. for ToC)
Fixed Value: Documents section

1..1

Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

Required Pattern: At least the following

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*