Clinical Practice Guidelines
2.0.0-ballot - ballot
Clinical Practice Guidelines
2.0.0-ballot - ballot
Clinical Practice Guidelines, published by HL7 International / Clinical Decision Support. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/cqf-recommendations/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-casesummary | Version: 2.0.0-ballot | |||
| Active as of 2024-04-14 | Computable Name: CPGCaseSummary | |||
CPG Case Summary is the set of case features and feature groups that completely represent the case data scoped by the clinical practice guideline. This expresses the complete patient state at any given point in time.
This is a domain case/instance profile
Examples:
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
 generatedFrom |
S | 0..1 | canonical() | Definition URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-generatedFrom |
| summaryFor |
S | 0..1 | Reference(CPG Case | CPG Care Plan | CPG Strategy | CPG Communication Request | CPG Immunization Request | CPG Propose Diagnosis Task | CPG Questionnaire Task | CPG Record Detected Issue Task | CPG Record Inference Task | CPG Medicaiton Request | CPG Report Flag Task | CPG Service Request) | Which case? URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-summaryFor |
 identifier |
S | 0..1 | Identifier | Version-independent identifier for the Composition |
| status |
S | 1..1 | code | preliminary | final | amended | entered-in-error |
| type |
S | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) |
| category |
S | 0..* | CodeableConcept | Categorization of Composition |
 subject |
S | 0..1 | Reference(CPG Patient) | Who and/or what the composition is about |
| encounter |
S | 0..1 | Reference(CPG Encounter) | Context of the Composition |
| date |
S | 1..1 | dateTime | Composition editing time |
 author |
S | 1..* | Reference(CPG Practitioner | CPG Practitioner Role) | Who and/or what authored the composition |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| generatedFrom |
S | 0..1 | canonical() | Definition URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-generatedFrom |
| summaryFor |
S | 0..1 | Reference(CPG Case | CPG Care Plan | CPG Strategy | CPG Communication Request | CPG Immunization Request | CPG Propose Diagnosis Task | CPG Questionnaire Task | CPG Record Detected Issue Task | CPG Record Inference Task | CPG Medicaiton Request | CPG Report Flag Task | CPG Service Request) | Which case? URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-summaryFor |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
 identifier |
SΣ | 0..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. |
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. |
| category |
SΣ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| subject |
SΣ | 0..1 | Reference(CPG Patient) | Who and/or what the composition is about |
| encounter |
SΣ | 0..1 | Reference(CPG Encounter) | Context of the Composition |
| date |
SΣ | 1..1 | dateTime | Composition editing time |
| author |
SΣ | 1..* | Reference(CPG Practitioner | CPG Practitioner Role) | Who and/or what authored the composition |
| title |
Σ | 1..1 | string | Human Readable name/title |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | |
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | |
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.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-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| 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 | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| 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 | |||||
| generatedFrom |
S | 0..1 | canonical() | Definition URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-generatedFrom | ||||
| summaryFor |
S | 0..1 | Reference(CPG Case | CPG Care Plan | CPG Strategy | CPG Communication Request | CPG Immunization Request | CPG Propose Diagnosis Task | CPG Questionnaire Task | CPG Record Detected Issue Task | CPG Record Inference Task | CPG Medicaiton Request | CPG Report Flag Task | CPG Service Request) | Which case? URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-summaryFor | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
SΣ | 0..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. | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||
| category |
SΣ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
SΣ | 0..1 | Reference(CPG Patient) | Who and/or what the composition is about | ||||
| encounter |
SΣ | 0..1 | Reference(CPG Encounter) | Context of the Composition | ||||
| date |
SΣ | 1..1 | dateTime | Composition editing time | ||||
| author |
SΣ | 1..* | Reference(CPG Practitioner | CPG Practitioner Role) | Who and/or what authored the composition | ||||
| title |
Σ | 1..1 | string | Human Readable name/title | ||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
 attester |
0..* | BackboneElement | Attests to accuracy of composition | |||||
 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 |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian |
Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo |
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 |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
  target[x] |
1..1 | Target of the relationship | ||||||
 targetIdentifier |
Identifier | |||||||
| targetReference |
Reference(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 |
C | 0..* | BackboneElement | Composition is broken into sections 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 |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| 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 |
C | 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. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26from the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.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-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Must-Support: 10 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| generatedFrom |
S | 0..1 | canonical() | Definition URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-generatedFrom |
| summaryFor |
S | 0..1 | Reference(CPG Case | CPG Care Plan | CPG Strategy | CPG Communication Request | CPG Immunization Request | CPG Propose Diagnosis Task | CPG Questionnaire Task | CPG Record Detected Issue Task | CPG Record Inference Task | CPG Medicaiton Request | CPG Report Flag Task | CPG Service Request) | Which case? URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-summaryFor |
| identifier |
S | 0..1 | Identifier | Version-independent identifier for the Composition |
| status |
S | 1..1 | code | preliminary | final | amended | entered-in-error |
| type |
S | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) |
| category |
S | 0..* | CodeableConcept | Categorization of Composition |
| subject |
S | 0..1 | Reference(CPG Patient) | Who and/or what the composition is about |
| encounter |
S | 0..1 | Reference(CPG Encounter) | Context of the Composition |
| date |
S | 1..1 | dateTime | Composition editing time |
| author |
S | 1..* | Reference(CPG Practitioner | CPG Practitioner Role) | Who and/or what authored the composition |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| generatedFrom |
S | 0..1 | canonical() | Definition URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-generatedFrom |
| summaryFor |
S | 0..1 | Reference(CPG Case | CPG Care Plan | CPG Strategy | CPG Communication Request | CPG Immunization Request | CPG Propose Diagnosis Task | CPG Questionnaire Task | CPG Record Detected Issue Task | CPG Record Inference Task | CPG Medicaiton Request | CPG Report Flag Task | CPG Service Request) | Which case? URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-summaryFor |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier |
SΣ | 0..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. |
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. |
| category |
SΣ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| subject |
SΣ | 0..1 | Reference(CPG Patient) | Who and/or what the composition is about |
| encounter |
SΣ | 0..1 | Reference(CPG Encounter) | Context of the Composition |
| date |
SΣ | 1..1 | dateTime | Composition editing time |
| author |
SΣ | 1..* | Reference(CPG Practitioner | CPG Practitioner Role) | Who and/or what authored the composition |
| title |
Σ | 1..1 | string | Human Readable name/title |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | |
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | |
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.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-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| 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 | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| 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 | |||||
| generatedFrom |
S | 0..1 | canonical() | Definition URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-generatedFrom | ||||
| summaryFor |
S | 0..1 | Reference(CPG Case | CPG Care Plan | CPG Strategy | CPG Communication Request | CPG Immunization Request | CPG Propose Diagnosis Task | CPG Questionnaire Task | CPG Record Detected Issue Task | CPG Record Inference Task | CPG Medicaiton Request | CPG Report Flag Task | CPG Service Request) | Which case? URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-summaryFor | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
SΣ | 0..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. | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||
| category |
SΣ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
SΣ | 0..1 | Reference(CPG Patient) | Who and/or what the composition is about | ||||
| encounter |
SΣ | 0..1 | Reference(CPG Encounter) | Context of the Composition | ||||
| date |
SΣ | 1..1 | dateTime | Composition editing time | ||||
| author |
SΣ | 1..* | Reference(CPG Practitioner | CPG Practitioner Role) | Who and/or what authored the composition | ||||
| title |
Σ | 1..1 | string | Human Readable name/title | ||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester |
0..* | BackboneElement | Attests to accuracy of composition | |||||
| 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 |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian |
Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo |
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 |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] |
1..1 | Target of the relationship | ||||||
| targetIdentifier |
Identifier | |||||||
| targetReference |
Reference(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 |
C | 0..* | BackboneElement | Composition is broken into sections 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 |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| 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 |
C | 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. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26from the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.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-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Must-Support: 10 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Other representations of profile: CSV, Excel, Schematron
IG © 2023+ HL7 International / Clinical Decision Support. Package hl7.fhir.uv.cpg#2.0.0-ballot based on FHIR 4.0.1. Generated 2024-04-14
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