An attachment packet: the ordered set of chart items assembled to travel with an outbound
artifact -- a letter today, an eReferral next, and forms, emails and chart prints after that.
Elements / Details
Every element this profile touches, with its full definition. Element names in the tables link here.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
A set of rules under which this content was created
Definition
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Comments
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Cardinality
0..1
Type
uri
Modifier
yes — This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
Comments
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
Definition
A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Comments
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Comments
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Does the render lead with a generated cover page? (absent = not stated, NOT false)
Definition
May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality
0..*
Type
Extension
Modifier
yes — Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
current (live assembly) | retired (superseded) | entered-in-error
Definition
Indicates the current state of this list.
Comments
This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Cardinality
1..1
Type
code
Must Support
yes
Modifier
yes — This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
How this list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.
Requirements
Lists are used in various ways, and it must be known in what way it is safe to use them.
Comments
This element is labeled as a modifier because a change list must not be misunderstood as a complete list.
Cardinality
1..1
Type
code
Modifier
yes — If set to "changes", the list is considered incomplete, while the other two codes indicate the list is complete, which changes the understanding of the elements listed
The packet's name, as shown where it is assembled and reviewed
Definition
A human-readable name for this assembly, shown in the attachment surface that built it and beside the record of what was sent. Names the packet's purpose rather than its members ("Enclosures - Internal Medicine referral letter"), because membership is entry and changes while the packet is being assembled.
Requirements
Allows customization beyond just the code identifying the kind of list.
Identifies how current the list is which affects relevance.
Comments
The actual important date is the date of currency of the resources that were summarized, but it is usually assumed that these are current when the preparation occurs.
Who and/or what defined the list contents (aka Author)
Definition
The entity responsible for deciding what the contents of the list were. Where the list was created by a human, this is the same as the author of the list.
Requirements
Allows follow-up as well as context.
Comments
The primary source is the entity that made the decisions what items are in the list. This may be software or user.
Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.
Comments
Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.
One member of the packet. List.entry is ORDERED, and the order is the order the members appear in
the outbound render.
entry.item is deliberately unconstrained as to resource type: the packet carries what a clinician
chose to send, and enumerating the types would reintroduce the per-type modelling this profile
exists to replace. A consumer renders the kinds it knows and reports the ones it does not, rather
than dropping them silently.
An entry MAY carry nexus-attachment-packet-excluded-page extensions naming pages of that member
the assembler left out.
Comments
If there are no entries in the list, an emptyReason SHOULD be provided.
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
A page of this member excluded from the render (1-based; repeats)
Definition
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extensions that cannot be ignored even if unrecognized
Definition
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality
0..*
Type
Extension
Modifier
yes — Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
The flag allows the system constructing the list to indicate the role and significance of the item in the list.
Requirements
This field is present to support various clinical uses of lists, such as a discharge summary medication list, where flags specify whether the medication was added, modified, or deleted from the list.
Comments
The flag can only be understood in the context of the List.code. If the flag means that the entry has actually been deleted from the list, the deleted element SHALL be true. Deleted can only be used if the List.mode is "changes".
True if this item is marked as deleted in the list.
Requirements
The flag element may contain codes that an application processing the list does not understand. However there can be no ambiguity if a list item is actually marked as "deleted".
Comments
If the flag means that the entry has actually been deleted from the list, the deleted element SHALL be true. Both flag and deleted can only be used if the List.mode is "changes". A deleted entry should be displayed in narrative as deleted. This element is labeled as a modifier because it indicates that an item is (to be) no longer in the list.
Cardinality
0..1
Type
boolean
Modifier
yes — If deleted is true, then the item included in the list isn't actually part of the list anymore
The chart item -- a document, note, result or form; SHALL be about this packet's subject
Definition
A reference to the actual resource from which data was derived.
Comments
Every member SHALL be about the patient in List.subject. A packet is assembled from one
chart and travels to an external recipient, so a member belonging to a different patient is
cross-patient disclosure at the moment the host is sent.
No validator enforces this, and that is a limitation to design around rather than a gap to
ignore. FHIRPath cannot resolve a reference, so the rule is not expressible as an invariant, and
entry.item is deliberately Reference(Resource) so no type constraint narrows it either. A
packet naming another patient's document is therefore structurally valid. Enforcement belongs where
the write happens and the reference can be resolved: a server accepting a packet SHALL reject a
member whose subject is not the packet's subject.
A consumer that did not assemble the packet should not assume the rule held: resolve the members
and check, rather than trusting List.subject to describe all of them.
Allows capturing things like "none exist" or "not asked" which can be important for most lists.
Comments
The various reasons for an empty list make a significant interpretation to its interpretation. Note that this code is for use when the entire list has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.