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Structured Documents icon Work GroupMaturity Level: 2 Trial UseSecurity Category: Not Classified Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the Composition resource.

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.).

Short DisplayA set of resources composed into a single coherent clinical statement with clinical attestation
Cardinality0..*
TypeDomainResource
Requirements

To support documents, and also to capture the EN13606 notion of an attested commit to the patient EHR, and to allow a set of disparate resources at the information/engineering level to be gathered into a clinical statement.

Summaryfalse
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.

Composition.url
Element IdComposition.url
Definition

An absolute URI that is used to identify this Composition when it is referenced in a specification, model, design or an instance; also called its canonical identifier. This SHOULD be globally unique and SHOULD be a literal address at which an authoritative instance of this Composition is (or will be) published. This URL can be the target of a canonical reference. It SHALL remain the same when the Composition is stored on different servers.

Short DisplayCanonical identifier for this Composition, represented as a URI (globally unique)
Cardinality0..1
Typeuri
Requirements

Allows the Composition to be referenced by a single globally unique identifier.

Summarytrue
Comments

Can be a urn:uuid: or a urn:oid: but real http: addresses are preferred. Multiple instances may share the same URL if they have a distinct version.

Composition.identifier
Element IdComposition.identifier
Definition

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

Short DisplayVersion-independent identifier for the Composition
NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Summarytrue
Comments

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

Composition.version
Element IdComposition.version
Definition

An explicitly assigned identifer of a variation of the content in the Composition.

Short DisplayAn explicitly assigned identifer of a variation of the content in the Composition
NoteThis is a business versionId, not a resource version id (see discussion)
Cardinality0..1
Typestring
Summarytrue
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.

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.

Short Displayregistered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
Cardinality1..1
Terminology BindingCompositionStatus (Required)
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.

Summarytrue
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.

Short DisplayKind of composition (LOINC if possible)
Cardinality1..1
Terminology BindingFHIR Document Type Codes (Preferred)
TypeCodeableConcept
Requirements

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

Summarytrue
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.

Short DisplayCategorization of Composition
Cardinality0..*
Terminology BindingReferenced Item Category Value Set (Example)
TypeCodeableConcept
Requirements

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

Summarytrue
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).

Short DisplayWho and/or what the composition is about
Cardinality0..*
TypeReference(Any)
Requirements

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

Summarytrue
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.

Short DisplayContext of the Composition
Cardinality0..1
TypeReference(Encounter)
Requirements

Provides context for the composition and supports searching.

Summarytrue
Composition.date
Element IdComposition.date
Definition

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

Short DisplayComposition editing time
Cardinality1..1
TypedateTime
Requirements

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

Summarytrue
Comments

The Last Modified Date on the composition may be after the date of the document was attested without being changed. This means that the date on an amended document is the date of the amendment, not the date of original authorship.

Composition.useContext
Element IdComposition.useContext
Definition

The content was developed with a focus and intent of supporting the contexts that are listed. These contexts may be general categories (gender, age, ...) or may be references to specific programs (insurance plans, studies, ...) and may be used to assist with indexing and searching for appropriate Composition instances.

Short DisplayThe context that the content is intended to support
Cardinality0..*
TypeUsageContext
Requirements

Assist in searching for appropriate content.

Summarytrue
Comments

When multiple useContexts are specified, there is no expectation that all or any of the contexts apply.

Composition.author
Element IdComposition.author
Definition

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

Short DisplayWho and/or what authored the composition
Cardinality1..*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Summarytrue
Composition.name
Element IdComposition.name
Definition

A natural language name identifying the {{title}}. This name should be usable as an identifier for the module by machine processing applications such as code generation.

Short DisplayName for this Composition (computer friendly)
Cardinality0..1
Typestring
Requirements

Support human navigation and code generation.

Summarytrue
Comments

The name is not expected to be globally unique. The name should be a simple alphanumeric type name to ensure that it is machine-processing friendly.

Composition.title
Element IdComposition.title
Definition

Official human-readable label for the composition.

Short DisplayHuman Readable name/title
Cardinality1..1
Typestring
Summarytrue
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.note
Element IdComposition.note
Definition

For any additional notes.

Short DisplayFor any additional notes
Cardinality0..*
TypeAnnotation
Summaryfalse
Comments

A comment, general note or annotation not coded elsewhere.

Composition.attester
Element IdComposition.attester
Definition

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

Short DisplayAttests to accuracy of composition
Cardinality0..*
Requirements

Identifies responsibility for the accuracy of the composition content.

Summaryfalse
Comments

Only list each attester once.

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

The type of attestation the authenticator offers.

Short Displaypersonal | professional | legal | official
Cardinality1..1
Terminology BindingCompositionAttestationMode (Preferred)
TypeCodeableConcept
Requirements

Indicates the level of authority of the attestation.

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

When the composition was attested by the party.

Short DisplayWhen the composition was attested
Cardinality0..1
TypedateTime
Requirements

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

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

Who attested the composition in the specified way.

Short DisplayWho attested the composition
Cardinality0..1
TypeReference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
Requirements

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

Summaryfalse
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.

Short DisplayOrganization which maintains the composition
Cardinality0..1
TypeReference(Organization)
Requirements

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

Summarytrue
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.

Short DisplayRelationships to other compositions/documents
Cardinality0..*
TypeRelatedArtifact
Summaryfalse
Comments

To reference (using relatesTo) a Bundle of type "document" or another Composition where you only have the identifier, use a resourceReference with an identifier. Here is an example of using relatesTo to reference another Bundle of type "document" or Composition where you only have the identifier:

\<relatesTo  >
    \<type value="replaces" />
\<resourceReference>
\<identifier>
\<system value="..." />
\<value value="..." />
</identifier>
</resourceReference>
</relatesTo>
Composition.event
Element IdComposition.event
Definition

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

Short DisplayThe clinical service(s) being documented
Cardinality0..*
Requirements

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

Summarytrue
Comments

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

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.

Short DisplayCode(s) that apply to the event being documented
Cardinality0..*
Terminology Bindingv3 Code System ActCode icon (Example)
TypeCodeableConcept
Summarytrue
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.

Short DisplayThe period covered by the documentation
Cardinality0..1
TypePeriod
Summarytrue
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.

Short DisplayThe event(s) being documented
Cardinality0..*
TypeReference(Any)
Summarytrue
Composition.section
Element IdComposition.section
Definition

The root of the sections that make up the composition.

Short DisplayComposition is broken into sections
Cardinality0..*
Summaryfalse
Invariants
Defined on this element
cmp-1Rule A section must contain at least one of text, entries, or sub-sectionstext.exists() or entry.exists() or section.exists()
cmp-2Rule A section can only have an emptyReason if it is emptyemptyReason.empty() or entry.empty()
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.

Short DisplayLabel for section (e.g. for ToC)
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
Summaryfalse
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.

Short DisplayClassification of section (recommended)
Cardinality0..1
Terminology BindingDocument Section Codes (Example)
TypeCodeableConcept
Requirements

Provides computable standardized labels to topics within the document.

Summaryfalse
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.

Short DisplayWho and/or what authored the section
Cardinality0..*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
Requirements

Identifies who is responsible for the content.

Summaryfalse
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).

Short DisplayWho/what the section is about, when it is not about the subject of composition
Cardinality0..1
TypeReference(Any)
Summaryfalse
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.

Short DisplayText summary of the section, for human interpretation
Cardinality0..1
TypeNarrative
Summaryfalse
Comments

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

Invariants
Affect this element
cmp-1Rule A section must contain at least one of text, entries, or sub-sectionstext.exists() or entry.exists() or section.exists()
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.

Short Displayworking | snapshot | changes
Cardinality0..1
Terminology BindingListMode (Required)
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.

Summaryfalse
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.

Short DisplayOrder of section entries
Cardinality0..1
Terminology BindingList Order Codes (Preferred)
TypeCodeableConcept
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Summaryfalse
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.

Short DisplayA reference to data that supports this section
Cardinality0..*
TypeReference(Any)
Summaryfalse
Comments

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

Invariants
Affect this element
cmp-2Rule A section can only have an emptyReason if it is emptyemptyReason.empty() or entry.empty()
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.

Short DisplayWhy the section is empty
Cardinality0..1
Terminology BindingList Empty Reasons (Preferred)
TypeCodeableConcept
Requirements

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

Summaryfalse
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.

Invariants
Affect this element
cmp-2Rule A section can only have an emptyReason if it is emptyemptyReason.empty() or entry.empty()
Composition.section.section
Element IdComposition.section.section
Definition

A nested sub-section within this section.

Short DisplayNested Section
Cardinality0..*
TypeSee Composition.section
Summaryfalse
Comments

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

Invariants
Affect this element
cmp-1Rule A section must contain at least one of text, entries, or sub-sectionstext.exists() or entry.exists() or section.exists()