PACIO Advance Directive Interoperability Implementation Guide
2.1.0 - STU 2
PACIO Advance Directive Interoperability Implementation Guide
2.1.0 - STU 2
PACIO Advance Directive Interoperability Implementation Guide, published by HL7 International / Patient Empowerment. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-pacio-adi/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-Composition-Header | Version: 2.1.0 | |||
| Active as of 2024-07-26 | Computable Name: ADICompositionHeader | |||
This abstract profile defines constraints that represent common administrative and demographic concepts for advance directives information used in US Realm clinical documents.
This profile, largely based on the CCDA on FHIR US Realm Header profile, defines requirements that address specific exchange requirements for a composition containing a person’s advance care plan information.
Conformance:
In the cases where the patient is not able to “write” the PACP contents due to literacy constraints or physical disability, e.g. hemiplegia, the patient/subject is still considered author of the content, and a data enterer will fill the role of physically creating the document by entering the author’s requested information into the system used to create the document.
Advance Directive Information VersionNumber Extension represents a numeric value used to version successive replacement documents. Best practice for systems that support distributed document creation and updating is to populate the versionNumber with the timestamp created from the date/time when the version of the document is created in the system. Note: this may or may not be equivalent to the timestamp integer for Composition.date. the versionNumber timestamp always will be equivalent to the Bundle.timestamp for the document.
For documents created within a system will follow the pattern that the timestamp-label versionNumber will be equivalent to the timestamp of the Composition.date and the Bundle.timestamp. However, for unstructured historical documents uploaded into a system, the timestamp-label versionNumber will be equivalent to the timestamp of the the Bundle.timestamp, but the Composition.date will reflect the creation date of the original document.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Clinical Document
| Path | Conformance | ValueSet | URI |
| Composition.status | required | ADICompositionStatusVShttp://hl7.org/fhir/us/pacio-adi/ValueSet/ADICompositionStatusVSfrom this IG | |
| Composition.type | extensible | AdvanceDirectivesCategories  http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.69.4 |
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | ADICompositionStatusVShttp://hl7.org/fhir/us/pacio-adi/ValueSet/ADICompositionStatusVSfrom this IG | ||||
| Composition.type | extensible | AdvanceDirectivesCategories http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.69.4 | ||||
| Composition.category | example | Pattern: LOINC Code 42348-3("Advance directives")http://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
  Composition |
0..* | Clinical Document | This is an abstractprofile. Childprofiles: ADIPACPComposition, ADIPMOComposition 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 |
S | 1..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 | |||||
   versionNumber |
0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| VersionNumber |
S | 0..1 | integer | Version Number URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-versionNumber-extension | ||||
| EffectiveDateExtension |
0..1 | Period | Effective Date URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-effective-date-extension | |||||
| Jurisdiction |
0..* | CodeableConcept | Jurisdiction URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-jurisdiction-extension Binding: Jurisdiction ValueSet (extensible) | |||||
| DataEntererExtension |
0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Data Enterer URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-dataEnterer-extension | |||||
| InformantExtension |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Informant URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-informant-extension | |||||
| ParticipantExtension |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | RelatedPerson) | Participant URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-participant-extension | |||||
| PerformerExtension |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Performer URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-performer-extension | |||||
| ClauseExtension |
0..* | (Complex) | Clause URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-clause-extension | |||||
 DocumentRevokeStatusExtension |
S | 0..1 | code | Revoke Status URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-document-revoke-status-extension Binding: ADI Document Revoke Status (required) | ||||
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
SΣ | 1..1 | Identifier | Version-independent identifier for the Composition | ||||
| status |
?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: ADI Composition Status (required) | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: Advance Directives Categories (extensible) | ||||
| category |
SΣ | 0..1 | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. 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: 42348-3 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Advance directives | |||||
 userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
 subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the composition is about | ||||
| encounter |
Σ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
| date |
SΣ | 1..1 | dateTime | Composition editing time | ||||
| author |
SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | ||||
| title |
SΣ | 1..1 | string | Human Readable name/title | ||||
| 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 |
SΣ | 1..1 | Reference(US Core Organization Profile) | 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 | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| ClauseExtension |
0..* | (Complex) | Clause URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-clause-extension | |||||
| 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 / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | ADICompositionStatusVShttp://hl7.org/fhir/us/pacio-adi/ValueSet/ADICompositionStatusVSfrom this IG | ||||
| Composition.type | extensible | AdvanceDirectivesCategories http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.69.4 | ||||
| Composition.category | example | Pattern: LOINC Code 42348-3("Advance directives")http://hl7.org/fhir/ValueSet/document-classcodesfrom 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 |
This structure is derived from Clinical Document
Summary
Mandatory: 4 elements
Must-Support: 11 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from Clinical Document
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Clinical Document | This is an abstractprofile. Childprofiles: ADIPACPComposition, ADIPMOComposition A set of resources composed into a single coherent clinical statement with clinical attestation | |
| language |
S | 1..1 | code | Language of the resource content |
 Slices for extension |
Content/Rules for all slices | |||
| VersionNumber |
S | 0..1 | integer | Version Number URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-versionNumber-extension |
| EffectiveDateExtension |
0..1 | Period | Effective Date URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-effective-date-extension | |
| Jurisdiction |
0..* | CodeableConcept | Jurisdiction URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-jurisdiction-extension Binding: Jurisdiction ValueSet (extensible) | |
| DataEntererExtension |
0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Data Enterer URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-dataEnterer-extension | |
| InformantExtension |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Informant URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-informant-extension | |
| ParticipantExtension |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | RelatedPerson) | Participant URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-participant-extension | |
| PerformerExtension |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Performer URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-performer-extension | |
| ClauseExtension |
0..* | (Complex) | Clause URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-clause-extension | |
| DocumentRevokeStatusExtension |
S | 0..1 | code | Revoke Status URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-document-revoke-status-extension Binding: ADI Document Revoke Status (required) |
| identifier |
S | 1..1 | Identifier | Version-independent identifier for the Composition |
| status |
1..1 | code | preliminary | final | amended | entered-in-error Binding: ADI Composition Status (required) | |
| type |
S | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: Advance Directives Categories (extensible) |
| category |
S | 0..1 | CodeableConcept | Categorization of Composition 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: 42348-3 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Advance directives | |
| subject |
S | 1..1 | Reference(US Core Patient Profile) | Who and/or what the composition is about |
| encounter |
0..1 | Reference(US Core Encounter Profile) | Context of the Composition | |
| date |
S | 1..1 | dateTime | Composition editing time |
| author |
S | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition |
| title |
S | 1..1 | string | Human Readable name/title |
| confidentiality |
0..0 | |||
| custodian |
S | 1..1 | Reference(US Core Organization Profile) | Organization which maintains the composition |
| section |
||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| ClauseExtension |
0..* | (Complex) | Clause URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-clause-extension | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.status | required | ADICompositionStatusVShttp://hl7.org/fhir/us/pacio-adi/ValueSet/ADICompositionStatusVSfrom this IG | |
| Composition.type | extensible | AdvanceDirectivesCategories http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.69.4 |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | Clinical Document | This is an abstractprofile. Childprofiles: ADIPACPComposition, ADIPMOComposition 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 | ||||
| language |
S | 1..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| ||||
| Slices for extension |
Content/Rules for all slices | |||||||
| versionNumber |
0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| VersionNumber |
S | 0..1 | integer | Version Number URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-versionNumber-extension | ||||
| EffectiveDateExtension |
0..1 | Period | Effective Date URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-effective-date-extension | |||||
| Jurisdiction |
0..* | CodeableConcept | Jurisdiction URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-jurisdiction-extension Binding: Jurisdiction ValueSet (extensible) | |||||
| DataEntererExtension |
0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Data Enterer URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-dataEnterer-extension | |||||
| InformantExtension |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Informant URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-informant-extension | |||||
| ParticipantExtension |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | RelatedPerson) | Participant URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-participant-extension | |||||
| PerformerExtension |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Performer URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-performer-extension | |||||
| ClauseExtension |
0..* | (Complex) | Clause URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-clause-extension | |||||
| DocumentRevokeStatusExtension |
S | 0..1 | code | Revoke Status URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-document-revoke-status-extension Binding: ADI Document Revoke Status (required) | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
SΣ | 1..1 | Identifier | Version-independent identifier for the Composition | ||||
| status |
?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: ADI Composition Status (required) | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: Advance Directives Categories (extensible) | ||||
| category |
SΣ | 0..1 | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. 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: 42348-3 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Advance directives | |||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the composition is about | ||||
| encounter |
Σ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
| date |
SΣ | 1..1 | dateTime | Composition editing time | ||||
| author |
SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | ||||
| title |
SΣ | 1..1 | string | Human Readable name/title | ||||
| custodian |
SΣ | 1..1 | Reference(US Core Organization Profile) | Organization which maintains the composition | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | ADICompositionStatusVShttp://hl7.org/fhir/us/pacio-adi/ValueSet/ADICompositionStatusVSfrom this IG | ||||
| Composition.type | extensible | AdvanceDirectivesCategories http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.69.4 | ||||
| Composition.category | example | Pattern: LOINC Code 42348-3("Advance directives")http://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | Clinical Document | This is an abstractprofile. Childprofiles: ADIPACPComposition, ADIPMOComposition 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 |
S | 1..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 | |||||
| versionNumber |
0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |||||
| VersionNumber |
S | 0..1 | integer | Version Number URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-versionNumber-extension | ||||
| EffectiveDateExtension |
0..1 | Period | Effective Date URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-effective-date-extension | |||||
| Jurisdiction |
0..* | CodeableConcept | Jurisdiction URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-jurisdiction-extension Binding: Jurisdiction ValueSet (extensible) | |||||
| DataEntererExtension |
0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Data Enterer URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-dataEnterer-extension | |||||
| InformantExtension |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) | Informant URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-informant-extension | |||||
| ParticipantExtension |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | RelatedPerson) | Participant URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-participant-extension | |||||
| PerformerExtension |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Performer URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-performer-extension | |||||
| ClauseExtension |
0..* | (Complex) | Clause URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-clause-extension | |||||
| DocumentRevokeStatusExtension |
S | 0..1 | code | Revoke Status URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-document-revoke-status-extension Binding: ADI Document Revoke Status (required) | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
SΣ | 1..1 | Identifier | Version-independent identifier for the Composition | ||||
| status |
?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: ADI Composition Status (required) | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: Advance Directives Categories (extensible) | ||||
| category |
SΣ | 0..1 | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. 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: 42348-3 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Advance directives | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | Who and/or what the composition is about | ||||
| encounter |
Σ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | ||||
| date |
SΣ | 1..1 | dateTime | Composition editing time | ||||
| author |
SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | ||||
| title |
SΣ | 1..1 | string | Human Readable name/title | ||||
| 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 |
SΣ | 1..1 | Reference(US Core Organization Profile) | 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 | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| ClauseExtension |
0..* | (Complex) | Clause URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-clause-extension | |||||
| 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 / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | ADICompositionStatusVShttp://hl7.org/fhir/us/pacio-adi/ValueSet/ADICompositionStatusVSfrom this IG | ||||
| Composition.type | extensible | AdvanceDirectivesCategories http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.69.4 | ||||
| Composition.category | example | Pattern: LOINC Code 42348-3("Advance directives")http://hl7.org/fhir/ValueSet/document-classcodesfrom 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 |
This structure is derived from Clinical Document
Summary
Mandatory: 4 elements
Must-Support: 11 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Other representations of profile: CSV, Excel, Schematron
IG © 2021+ HL7 International / Patient Empowerment. Package hl7.fhir.us.pacio-adi#2.1.0 based on FHIR 4.0.1. Generated 2024-07-26
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