Current Build
Structured Documents Work GroupMaturity Level: 2 Trial UseCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the Composition resource.

Composition
Definition

A set of healthcare-related information that is assembled together into a single logical document 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. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.

Control1..1
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.

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.identifier
Definition

Logical identifier for the composition, assigned when created. This identifier stays constant as the composition is changed over time.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
Summarytrue
Comments

See discussion in resource definition for how these relate.

Composition.status
Definition

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

Control1..1
Terminology BindingCompositionStatus (Required)
Typecode
Is Modifiertrue
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Need to be able to mark interim, amended, or withdrawn compositions or documents.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If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as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
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.

Control1..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.class
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.

Control0..1
Terminology BindingFHIR Document Class Codes (Example)
TypeCodeableConcept
Requirements

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

Summarytrue
Comments

This is a metadata field from XDS/MHD .

Composition.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).

Control1..1
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
Definition

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

Control0..1
TypeReference(Encounter)
Requirements

Provides context for the composition and supports searching.

Summarytrue
Composition.date
Definition

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

Control1..1
TypedateTime
Requirements

dateTime is used for tracking, organizing versions and searching.

Summarytrue
Comments

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

Composition.author
Definition

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

Control1..*
TypeReference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson)
Requirements

Identifies who is responsible for the content.

Summarytrue
Composition.title
Definition

Official human-readable label for the composition.

Control1..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.confidentiality
Definition

The code specifying the level of confidentiality of the Composition.

Control0..1
Terminology BindingConfidentialityClassification (Required)
Typecode
Is Modifiertrue
Summarytrue
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
Definition

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

Control0..*
Requirements

Identifies responsibility for the accuracy of the composition content.

Summarytrue
Comments

Only list each attester once.

Composition.attester.mode
Definition

The type of attestation the authenticator offers.

Control1..*
Terminology BindingCompositionAttestationMode (Required)
Typecode
Requirements

Indicates the level of authority of the attestation.

Summarytrue
Comments

Use more than one code where a single attester has more than one mode (professional and legal are often paired).

Composition.attester.time
Definition

When the composition was attested by the party.

Control0..1
TypedateTime
Requirements

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

Summarytrue
Composition.attester.party
Definition

Who attested the composition in the specified way.

Control0..1
TypeReference(Patient | Practitioner | PractitionerRole | Organization)
Requirements

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

Summarytrue
Composition.custodian
Definition

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

Control0..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
Definition

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

Control0..*
Summarytrue
Comments

A document is a version specific composition.

Composition.relatesTo.code
Definition

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

Control1..1
Terminology BindingDocumentRelationshipType (Required)
Typecode
Summarytrue
Comments

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

Composition.relatesTo.target[x]
Definition

The target composition/document of this relationship.

Control1..1
TypeIdentifier|Reference(Composition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Composition.event
Definition

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

Control0..*
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
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.

Control0..*
Terminology Bindingv3 Code System ActCode (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
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.

Control0..1
TypePeriod
Summarytrue
Composition.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.

Control0..*
TypeReference(Any)
Summarytrue
Composition.section
Definition

The root of the sections that make up the composition.

Control0..*
InvariantsDefined on this element
cmp-1: A section must at least one of text, entries, or sub-sections (expression : text.exists() or entry.exists() or section.exists(), xpath: exists(f:text) or exists(f:entry) or exists(f:section))
cmp-2: A section can only have an emptyReason if it is empty (expression : emptyReason.empty() or entry.empty(), xpath: not(exists(f:emptyReason) and exists(f:entry)))
Composition.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.

Control0..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
Definition

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

Control0..1
Terminology BindingDocument Section Codes (Example)
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.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.

Control0..1
TypeNarrative
Comments

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

InvariantsAffect this element
cmp-1: A section must at least one of text, entries, or sub-sections (expression : text.exists() or entry.exists() or section.exists(), xpath: exists(f:text) or exists(f:entry) or exists(f:section))
Composition.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.

Control0..1
Terminology BindingListMode (Required)
Typecode
Is Modifiertrue
Requirements

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

Summarytrue
Comments

This element is labeled as a modifier because a change list must not be mis-understood as a complete list.

Composition.section.orderedBy
Definition

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

Control0..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.

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
Definition

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

Control0..*
TypeReference(Any)
Comments

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

InvariantsAffect this element
cmp-2: A section can only have an emptyReason if it is empty (expression : emptyReason.empty() or entry.empty(), xpath: not(exists(f:emptyReason) and exists(f:entry)))
Composition.section.emptyReason
Definition

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

Control0..1
Terminology BindingList Empty Reasons (Preferred)
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.

InvariantsAffect this element
cmp-2: A section can only have an emptyReason if it is empty (expression : emptyReason.empty() or entry.empty(), xpath: not(exists(f:emptyReason) and exists(f:entry)))
Composition.section.section
Definition

A nested sub-section within this section.

Control0..*
TypeSee Composition.section
Comments

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

InvariantsAffect this element
cmp-1: A section must at least one of text, entries, or sub-sections (expression : text.exists() or entry.exists() or section.exists(), xpath: exists(f:text) or exists(f:entry) or exists(f:section))