Australian Digital Health Agency FHIR Implementation Guide
1.2.0-ci-build - draft Australia flag

Australian Digital Health Agency FHIR Implementation Guide, published by Australian Digital Health Agency. This guide is not an authorized publication; it is the continuous build for version 1.2.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/AuDigitalHealth/ci-fhir-r4/ and changes regularly. See the Directory of published versions

Resource Profile: ADHA Personal Health Notes Document Composition

Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-composition-phn-1 Version: 0.0.3
Draft as of 2024-09-12 Computable Name: ADHACompositionPHN

Copyright/Legal: Copyright © 2022 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/.

The purpose of this profile is to define a representation of a Personal Health Notes document for a patient for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia. A composition is a set of resources composed into a single coherent clinical statement that may have clinical attestation.

This profile identifies the additional constraints, extensions, and value sets that build on and extend Composition that are supported.

Due to the nature of this document type with a single narrative only section, this profile supports the equivalent of a HL7 CDA instance conformance Level 1B, Level 2, Level 3A and 3B clinical document as defined in the Agency's Common Conformance Profile for Clinical Documents.

This profile is designed to set a Composition standard for:

  • Query for a Personal Health Notes document for a patient
  • Record or update a Personal Health Notes document for a patient

This profile may be referred to by APIs, which will be listed here when available.

Profile specific guidance

None.

Boundaries and relationships

This profile is not referenced by another profile in this implementation guide.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from ADHACompositionDocument

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..* ADHACompositionDocument Personal Health Notes
... status 1..1 code preliminary | final | amended | entered-in-error
Required Pattern: final
... type 1..1 CodeableConcept Document sub type
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51855-5
... Slices for category 1..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by pattern:$this
.... category:phn 1..1 CodeableConcept Personal Health Notes
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.16681
... section 1..1 BackboneElement Notes
.... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51855-5
.... entry 0..0
.... emptyReason 0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition C 0..* ADHACompositionDocument Personal Health Notes
inv-dh-doc-01: If present, an information recipient shall at least have a reference, an identifier or a display
inv-dh-doc-02: Sections shall be unique by code
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... informationRecipient SC 0..* Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) Information recipient
URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.


Required Pattern: final
... type SΣ 1..1 CodeableConcept Document sub type
Binding: My Health Record Record Type . (extensible)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51855-5
... Slices for category SΣ 1..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by pattern:$this
Binding: My Health Record Record Class . (extensible)
.... category:phn SΣ 1..1 CodeableConcept Personal Health Notes
Binding: My Health Record Record Class . (extensible)

Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.16681
... subject SΣC 1..1 Reference(ADHA Core Patient) Who and/or what the composition is about
inv-dh-doc-03: At least reference or a valid identifier shall be present
... encounter SΣ 0..1 Reference(ADHA Core Encounter) Context of the Composition
... date SΣC 1..1 dateTime Composition editing time
inv-dh-doc-07: Date shall be at least to day
... author SΣC 1..1 Reference(ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Authoring Care Agency Employee) Who and/or what authored the composition
inv-dh-doc-04: At least reference or a valid identifier shall be present
... title SΣ 1..1 string Human Readable name/title
... attester SC 0..* BackboneElement Attests to accuracy of composition
inv-dh-doc-05: The party shall at least have a reference or a valid identifier
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode S 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time S 1..1 dateTime When the composition was attested
.... party SC 1..1 Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Core Organization) Who attested the composition
... custodian SΣC 1..1 Reference(ADHA Core Organization) Organization which maintains the composition
inv-dh-doc-06: At least reference or a valid identifier shall be present
... relatesTo S 0..* BackboneElement Relationships to other compositions/documents
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code S 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] S 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(ADHA Core Composition)
... section SC 1..1 BackboneElement Notes
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... title S 0..1 string Label for section (e.g. for ToC)
.... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51855-5
.... text SC 0..1 Narrative Text summary of the section, for human interpretation

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.statusrequiredPattern: final
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typeextensiblePattern: LOINC Code 51855-5
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1
Composition.categoryextensibleMyHealthRecordRecordClass .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1
Composition.category:phnextensiblePattern: 100.16681
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.section.codeexamplePattern: LOINC Code 51855-5
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition C 0..* ADHACompositionDocument Personal Health Notes
inv-dh-doc-01: If present, an information recipient shall at least have a reference, an identifier or a display
inv-dh-doc-02: Sections shall be unique by code
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... informationRecipient SC 0..* Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) Information recipient
URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier Version-independent identifier for the Composition
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.


Required Pattern: final
... type SΣ 1..1 CodeableConcept Document sub type
Binding: My Health Record Record Type . (extensible)
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51855-5
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... Slices for category SΣ 1..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by pattern:$this
Binding: My Health Record Record Class . (extensible)
.... category:phn SΣ 1..1 CodeableConcept Personal Health Notes
Binding: My Health Record Record Class . (extensible)

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.16681
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... subject SΣC 1..1 Reference(ADHA Core Patient) Who and/or what the composition is about
inv-dh-doc-03: At least reference or a valid identifier shall be present
... encounter SΣ 0..1 Reference(ADHA Core Encounter) Context of the Composition
... date SΣC 1..1 dateTime Composition editing time
inv-dh-doc-07: Date shall be at least to day
... author SΣC 1..1 Reference(ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Authoring Care Agency Employee) Who and/or what authored the composition
inv-dh-doc-04: At least reference or a valid identifier shall be present
... title SΣ 1..1 string Human Readable name/title
... attester SC 0..* BackboneElement Attests to accuracy of composition
inv-dh-doc-05: The party shall at least have a reference or a valid identifier
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode S 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time S 1..1 dateTime When the composition was attested
.... party SC 1..1 Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Core Organization) Who attested the composition
... custodian SΣC 1..1 Reference(ADHA Core Organization) Organization which maintains the composition
inv-dh-doc-06: At least reference or a valid identifier shall be present
... relatesTo S 0..* BackboneElement Relationships to other compositions/documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code S 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] S 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(ADHA Core Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... section SC 1..1 BackboneElement Notes
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... title S 0..1 string Label for section (e.g. for ToC)
.... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51855-5
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
.... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
.... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
.... text SC 0..1 Narrative Text summary of the section, for human interpretation
.... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.


Fixed Value: snapshot
.... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

.... section C 0..* See section (Composition) Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Composition.statusrequiredPattern: final
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typeextensiblePattern: LOINC Code 51855-5
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1
Composition.categoryextensibleMyHealthRecordRecordClass .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1
Composition.category:phnextensiblePattern: 100.16681
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexamplePattern: LOINC Code 51855-5
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredFixed Value: snapshot
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard

This structure is derived from ADHACompositionDocument

Differential View

This structure is derived from ADHACompositionDocument

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..* ADHACompositionDocument Personal Health Notes
... status 1..1 code preliminary | final | amended | entered-in-error
Required Pattern: final
... type 1..1 CodeableConcept Document sub type
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51855-5
... Slices for category 1..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by pattern:$this
.... category:phn 1..1 CodeableConcept Personal Health Notes
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.16681
... section 1..1 BackboneElement Notes
.... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51855-5
.... entry 0..0
.... emptyReason 0..0

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition C 0..* ADHACompositionDocument Personal Health Notes
inv-dh-doc-01: If present, an information recipient shall at least have a reference, an identifier or a display
inv-dh-doc-02: Sections shall be unique by code
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... informationRecipient SC 0..* Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) Information recipient
URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.


Required Pattern: final
... type SΣ 1..1 CodeableConcept Document sub type
Binding: My Health Record Record Type . (extensible)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51855-5
... Slices for category SΣ 1..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by pattern:$this
Binding: My Health Record Record Class . (extensible)
.... category:phn SΣ 1..1 CodeableConcept Personal Health Notes
Binding: My Health Record Record Class . (extensible)

Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.16681
... subject SΣC 1..1 Reference(ADHA Core Patient) Who and/or what the composition is about
inv-dh-doc-03: At least reference or a valid identifier shall be present
... encounter SΣ 0..1 Reference(ADHA Core Encounter) Context of the Composition
... date SΣC 1..1 dateTime Composition editing time
inv-dh-doc-07: Date shall be at least to day
... author SΣC 1..1 Reference(ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Authoring Care Agency Employee) Who and/or what authored the composition
inv-dh-doc-04: At least reference or a valid identifier shall be present
... title SΣ 1..1 string Human Readable name/title
... attester SC 0..* BackboneElement Attests to accuracy of composition
inv-dh-doc-05: The party shall at least have a reference or a valid identifier
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode S 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time S 1..1 dateTime When the composition was attested
.... party SC 1..1 Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Core Organization) Who attested the composition
... custodian SΣC 1..1 Reference(ADHA Core Organization) Organization which maintains the composition
inv-dh-doc-06: At least reference or a valid identifier shall be present
... relatesTo S 0..* BackboneElement Relationships to other compositions/documents
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code S 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] S 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(ADHA Core Composition)
... section SC 1..1 BackboneElement Notes
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... title S 0..1 string Label for section (e.g. for ToC)
.... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51855-5
.... text SC 0..1 Narrative Text summary of the section, for human interpretation

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.statusrequiredPattern: final
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typeextensiblePattern: LOINC Code 51855-5
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1
Composition.categoryextensibleMyHealthRecordRecordClass .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1
Composition.category:phnextensiblePattern: 100.16681
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.section.codeexamplePattern: LOINC Code 51855-5
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition C 0..* ADHACompositionDocument Personal Health Notes
inv-dh-doc-01: If present, an information recipient shall at least have a reference, an identifier or a display
inv-dh-doc-02: Sections shall be unique by code
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... informationRecipient SC 0..* Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) Information recipient
URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier Version-independent identifier for the Composition
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.


Required Pattern: final
... type SΣ 1..1 CodeableConcept Document sub type
Binding: My Health Record Record Type . (extensible)
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51855-5
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... Slices for category SΣ 1..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by pattern:$this
Binding: My Health Record Record Class . (extensible)
.... category:phn SΣ 1..1 CodeableConcept Personal Health Notes
Binding: My Health Record Record Class . (extensible)

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.16681
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... subject SΣC 1..1 Reference(ADHA Core Patient) Who and/or what the composition is about
inv-dh-doc-03: At least reference or a valid identifier shall be present
... encounter SΣ 0..1 Reference(ADHA Core Encounter) Context of the Composition
... date SΣC 1..1 dateTime Composition editing time
inv-dh-doc-07: Date shall be at least to day
... author SΣC 1..1 Reference(ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Authoring Care Agency Employee) Who and/or what authored the composition
inv-dh-doc-04: At least reference or a valid identifier shall be present
... title SΣ 1..1 string Human Readable name/title
... attester SC 0..* BackboneElement Attests to accuracy of composition
inv-dh-doc-05: The party shall at least have a reference or a valid identifier
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode S 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time S 1..1 dateTime When the composition was attested
.... party SC 1..1 Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Core Organization) Who attested the composition
... custodian SΣC 1..1 Reference(ADHA Core Organization) Organization which maintains the composition
inv-dh-doc-06: At least reference or a valid identifier shall be present
... relatesTo S 0..* BackboneElement Relationships to other compositions/documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code S 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] S 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(ADHA Core Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... section SC 1..1 BackboneElement Notes
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... title S 0..1 string Label for section (e.g. for ToC)
.... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.


Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51855-5
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
.... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
.... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
.... text SC 0..1 Narrative Text summary of the section, for human interpretation
.... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.


Fixed Value: snapshot
.... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

.... section C 0..* See section (Composition) Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Composition.statusrequiredPattern: final
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typeextensiblePattern: LOINC Code 51855-5
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1
Composition.categoryextensibleMyHealthRecordRecordClass .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1
Composition.category:phnextensiblePattern: 100.16681
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexamplePattern: LOINC Code 51855-5
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredFixed Value: snapshot
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard

This structure is derived from ADHACompositionDocument

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Below is an overview of the mandatory and optional search parameters. FHIR search operations and the syntax used to describe the interactions is described here.

Name Type Conformance Description Path
identifier token SHALL An identifier for the report Composition.identifier
category token SHALL Categorization of Composition Composition.category
subject:identifier token SHALL Who and/or what the composition is about Composition.subject.identifier
type token SHALL Kind of composition (LOINC if possible) Composition.code
date date SHALL Composition editing time Composition.effective
status token SHOULD preliminary | final | amended | entered-in-error Composition.status

Mandatory Search Parameters

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support searching for all compositions for a patient using the subject:identifier search parameter:

    GET [base]/Composition?subject:identifier={system|}[code]

    Example:

     GET [base]/Composition?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437
    

    Implementation Notes: Fetches a bundle of all Composition resources for the specified patient (how to search by :identifier)

  2. SHALL support searching using the identifier search parameter:

    GET [base]/Composition?identifier={system|}[code]

    Example:

     GET [base]/Composition?identifier=urn:ietf:rfc:3986|urn:uuid:b487469d-810c-40ae-b5a9-c0beb9001c9f
    

    Implementation Notes: Fetches a bundle containing any Composition resources matching the identifier (how to search by token)

  3. SHALL support searching using the combination subject:identifier and category search parameter:

    GET [base]/Composition?subject:identifier={system|}[code]&category[code]

    Example:

     GET [base]/Composition?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&category=https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1|100.16681
    

    Implementation Notes: Fetches a bundle of all Composition resources with the category of "Personal Health Notes" for the specified patient (how to search by :identifier and how to search by token)

  4. SHALL support searching using the combination subject:identifier and type search parameter:

    GET [base]/Composition?subject:identifier={system|}[code]&type={system|}[code]

    Example:

     GET [base]/Composition?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&type=https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1|100.16681
    

    Implementation Notes: Fetches a bundle of all Composition resources with the type of an 100.16681 (Personal Health Notes) for the specified patient (how to search by :identifier and how to search by token)

  5. SHALL support searching using the combination of the subject:identifier and date search parameters:

    GET [base]/Composition?subject:identifier={system|}[code]&date=[date]

    Example:

     GET [base]/Composition?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&date=ge2013-03-14
    

    Implementation Notes: Fetches a bundle of all Composition resources for the specified patient that have a date greater than or equal to 21st Jan 2013. (how to search by :identifier and how to search by date)