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Structured Documents Work Group Maturity Level: 1Trial Use Use Context: Any

Definitions for the clinicaldocument Profile.

Composition
Element IdComposition
Definition

A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).

Cardinality0..*
Comments

While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.

Invariants
Inherited by this element
dom-2RuleIf the resource is contained in another resource, it SHALL NOT contain nested Resourcescontained.contained.empty()
dom-3RuleIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resourcecontained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4RuleIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdatedcontained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5RuleIf a resource is contained in another resource, it SHALL NOT have a security labelcontained.meta.security.empty()
dom-6GuidelineA resource should have narrative for robust managementtext.div.exists()
This is (only) a best practice guideline because:

When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.

Composition.id
Element IdComposition.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Cardinality0..1
Typestring
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Composition.meta
Element IdComposition.meta
Definition

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.

Cardinality0..1
TypeMeta
Composition.implicitRules
Element IdComposition.implicitRules
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.

Cardinality0..1
Typeuri
Is Modifiertrue (Reason: 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)
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.

Composition.language
Element IdComposition.language
Definition

The base language in which the resource is written.

Cardinality0..1
Terminology BindingA human language.
The codes SHOULD be taken from Common Languages
Typecode
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).

Composition.text
Element IdComposition.text
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.

Cardinality0..1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
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.

Composition.contained
Element IdComposition.contained
Definition

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.

Cardinality0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
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.

Composition.extension
Element IdComposition.extension
Definition

An Extension

Cardinality0..*
TypeExtension
SlicingThis element introduces a set of slices. The slicing rules are:
  • unordered
  • Open
  • discriminators: value:url
Composition.extension(versionNumber)
Element IdComposition.extension:versionNumber
Definition

Version specific identifier for the composition, assigned when each version is created/updated.

Cardinality0..* This element is affected by the following invariants: ele-1
TypeExtension(versionNumber)
Comments

While each resource, including the composition itself, has its own version identifier, this is a formal identifier for the logical version of the composition as a whole. It would remain constant if the resources were moved to a new server, and all got new individual resource versions, for example.

Invariants
Inherited by this element
ele-1RuleAll FHIR elements must have a @value or childrenhasValue() or (children().count() > id.count())
ext-1RuleMust have either extensions or value[x], not bothextension.exists() != value.exists()
Composition.modifierExtension
Element IdComposition.modifierExtension
Definition

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).

Cardinality0..*
TypeExtension
Is Modifiertrue (Reason: Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them)
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 .

Alternate Namesextensions, user content
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.

Composition.identifier
Element IdComposition.identifier
Definition

A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.

Cardinality0..1
TypeIdentifier
Comments

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

Composition.status
Element IdComposition.status
Definition

The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.

Cardinality1..1
Terminology BindingThe workflow/clinical status of the composition.
The codes SHALL be taken from CompositionStatus
Typecode
Is Modifiertrue (Reason: This element is labelled 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)
Requirements

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Comments

If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements.

Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.

Composition.type
Element IdComposition.type
Definition

Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition.

Cardinality1..1
Terminology BindingType of a composition.
The codes SHOULD be taken from FHIR Document Type Codes
TypeCodeableConcept
Requirements

Key metadata element describing the composition, used in searching/filtering.

Comments

For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.

Composition.category
Element IdComposition.category
Definition

A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

Cardinality0..*
Terminology BindingHigh-level kind of a clinical document at a macro level.
For example codes, see Document Class Value Set
TypeCodeableConcept
Requirements

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Comments

This is a metadata field from XDS/MHD .

Composition.subject
Element IdComposition.subject
Definition

Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).

Cardinality0..1
TypeReference(Patient)
Requirements

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

Comments

For clinical documents, this is usually the patient.

Composition.encounter
Element IdComposition.encounter
Definition

Describes the clinical encounter or type of care this documentation is associated with.

Cardinality0..1
TypeReference(Encounter)
Requirements

Provides context for the composition and supports searching.

Composition.date
Element IdComposition.date
Definition

The composition editing time, when the composition was last logically changed by the author.

Cardinality1..1
TypedateTime
Requirements

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Comments

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

Composition.author
Element IdComposition.author
Definition

Identifies who is responsible for the information in the composition, not necessarily who typed it in.

Cardinality1..*
TypeReference(Practitioner)
Requirements

Identifies who is responsible for the content.

Composition.title
Element IdComposition.title
Definition

Official human-readable label for the composition.

Cardinality1..1
Typestring
Comments

For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.

Composition.confidentiality
Element IdComposition.confidentiality
Definition

The code specifying the level of confidentiality of the Composition.

Cardinality0..1
Terminology BindingCodes specifying the level of confidentiality of the composition.
The codes SHALL be taken from http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|4.1.0
Typecode
Comments

The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not.

Composition.attester
Element IdComposition.attester
Definition

A participant who has attested to the accuracy of the composition/document.

Cardinality0..*
TypeBackboneElement
Requirements

Identifies responsibility for the accuracy of the composition content.

Comments

Only list each attester once.

Invariants
Inherited by this element
ele-1RuleAll FHIR elements must have a @value or childrenhasValue() or (children().count() > id.count())
Composition.attester.id
Element IdComposition.attester.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Composition.attester.extension
Element IdComposition.attester.extension
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.

Cardinality0..*
TypeExtension
Alternate Namesextensions, user content
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.

Composition.attester.modifierExtension
Element IdComposition.attester.modifierExtension
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).

Cardinality0..*
TypeExtension
Is Modifiertrue (Reason: Modifier extensions are expected to modify the meaning or interpretation of the element that contains them)
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 .

Alternate Namesextensions, user content, modifiers
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.

Composition.attester.mode
Element IdComposition.attester.mode
Definition

The type of attestation the authenticator offers.

Cardinality1..1
Terminology BindingThe way in which a person authenticated a composition.
The codes SHALL be taken from CompositionAttestationMode
Typecode
Requirements

Indicates the level of authority of the attestation.

Composition.attester.time
Element IdComposition.attester.time
Definition

When the composition was attested by the party.

Cardinality0..1
TypedateTime
Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Composition.attester.party
Element IdComposition.attester.party
Definition

Who attested the composition in the specified way.

Cardinality0..1
TypeReference(Patient)
Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Composition.custodian
Element IdComposition.custodian
Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.

Cardinality0..1
TypeReference(Organization)
Requirements

Identifies where to go to find the current version, where to report issues, etc.

Comments

This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.

Composition.relatesTo
Element IdComposition.relatesTo
Definition

Relationships that this composition has with other compositions or documents that already exist.

Cardinality0..*
TypeBackboneElement
Comments

A document is a version specific composition.

Invariants
Inherited by this element
ele-1RuleAll FHIR elements must have a @value or childrenhasValue() or (children().count() > id.count())
Composition.relatesTo.id
Element IdComposition.relatesTo.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Composition.relatesTo.extension
Element IdComposition.relatesTo.extension
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.

Cardinality0..*
TypeExtension
Alternate Namesextensions, user content
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.

Composition.relatesTo.modifierExtension
Element IdComposition.relatesTo.modifierExtension
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).

Cardinality0..*
TypeExtension
Is Modifiertrue (Reason: Modifier extensions are expected to modify the meaning or interpretation of the element that contains them)
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 .

Alternate Namesextensions, user content, modifiers
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.

Composition.relatesTo.code
Element IdComposition.relatesTo.code
Definition

The type of relationship that this composition has with anther composition or document.

Cardinality1..1
Terminology BindingThe type of relationship between documents.
The codes SHALL be taken from DocumentRelationshipType
Typecode
Comments

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

Composition.relatesTo.target[x]
Element IdComposition.relatesTo.target[x]
Definition

The target composition/document of this relationship.

Cardinality1..1
TypeChoice of: Identifier, Reference(Composition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Composition.event
Element IdComposition.event
Definition

The clinical service, such as a colonoscopy or an appendectomy, being documented.

Cardinality0..*
TypeBackboneElement
Requirements

Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.

Comments

The event needs to be consistent with the type element, though can provide further information if desired.

Invariants
Inherited by this element
ele-1RuleAll FHIR elements must have a @value or childrenhasValue() or (children().count() > id.count())
Composition.event.id
Element IdComposition.event.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Composition.event.extension
Element IdComposition.event.extension
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.

Cardinality0..*
TypeExtension
Alternate Namesextensions, user content
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.

Composition.event.modifierExtension
Element IdComposition.event.modifierExtension
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).

Cardinality0..*
TypeExtension
Is Modifiertrue (Reason: Modifier extensions are expected to modify the meaning or interpretation of the element that contains them)
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 .

Alternate Namesextensions, user content, modifiers
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.

Composition.event.code
Element IdComposition.event.code
Definition

This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.

Cardinality0..*
Terminology BindingThis list of codes represents the main clinical acts being documented.
For example codes, see v3 Code System ActCode
TypeCodeableConcept
Comments

An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries.

Composition.event.period
Element IdComposition.event.period
Definition

The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.

Cardinality0..1
TypePeriod
Composition.event.detail
Element IdComposition.event.detail
Definition

The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.

Cardinality0..*
TypeReference(Resource)
Composition.section
Element IdComposition.section
Definition

The root of the sections that make up the composition.

Cardinality0..*
TypeBackboneElement
Invariants
Inherited by this element
ele-1RuleAll FHIR elements must have a @value or childrenhasValue() or (children().count() > id.count())
cmp-1RuleA section must contain at least one of text, entries, or sub-sectionstext.exists() or entry.exists() or section.exists()
cmp-2RuleA section can only have an emptyReason if it is emptyemptyReason.empty() or entry.empty()
Composition.section.id
Element IdComposition.section.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Composition.section.extension
Element IdComposition.section.extension
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.

Cardinality0..*
TypeExtension
Alternate Namesextensions, user content
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.

Composition.section.modifierExtension
Element IdComposition.section.modifierExtension
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).

Cardinality0..*
TypeExtension
Is Modifiertrue (Reason: Modifier extensions are expected to modify the meaning or interpretation of the element that contains them)
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 .

Alternate Namesextensions, user content, modifiers
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.

Composition.section.title
Element IdComposition.section.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

Cardinality0..1
Typestring
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Composition.section.code
Element IdComposition.section.code
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Cardinality0..1
Terminology BindingClassification of a section of a composition/document.
For example codes, see Document Section Codes
TypeCodeableConcept
Requirements

Provides computable standardized labels to topics within the document.

Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Composition.section.author
Element IdComposition.section.author
Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Cardinality0..*
TypeReference(Practitioner)
Requirements

Identifies who is responsible for the content.

Composition.section.focus
Element IdComposition.section.focus
Definition

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

Cardinality0..1
TypeReference(Resource)
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Composition.section.text
Element IdComposition.section.text
Definition

A human-readable narrative that contains the attested content of the section, 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.

Cardinality0..1 This element is affected by the following invariants: cmp-1
TypeNarrative
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Composition.section.mode
Element IdComposition.section.mode
Definition

How the entry 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.

Cardinality0..1
Terminology BindingThe processing mode that applies to this section.
The codes SHALL be taken from ListMode
Typecode
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Composition.section.orderedBy
Element IdComposition.section.orderedBy
Definition

Specifies the order applied to the items in the section entries.

Cardinality0..1
Terminology BindingWhat order applies to the items in the entry.
The codes SHOULD be taken from List Order Codes
TypeCodeableConcept
Requirements

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.

Composition.section.entry
Element IdComposition.section.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

Cardinality0..* This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Composition.section.emptyReason
Element IdComposition.section.emptyReason
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Cardinality0..1 This element is affected by the following invariants: cmp-2
Terminology BindingIf a section is empty, why it is empty.
The codes SHOULD be taken from List Empty Reasons
TypeCodeableConcept
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content 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.

Composition.section.section
Element IdComposition.section.section
Definition

A nested sub-section within this section.

Cardinality0..* This element is affected by the following invariants: cmp-1
TypeSee Composition.section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.