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2.8 Resource Composition - Content

Structured Documents icon Work GroupMaturity Level: 4 Trial UseSecurity Category: Not Classified Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).

2.8.1 Scope and Usage

A Composition is the basic structure from which FHIR Documents - immutable bundles with attested narrative - are built. A single logical composition may be associated with a series of derived documents, each of which is a frozen copy of the composition.

Note: EN 13606 icon uses the term "Composition" to refer to a single commit to an EHR system, and offers some common examples: a composition containing a consultation note, a progress note, a report or a letter, an investigation report, a prescription form or a set of bedside nursing observations. Using Composition for an attested EHR commit is a valid use of the Composition resource, but for FHIR purposes, it would be usual to make more granular updates with individual provenance statements.

The Clinical Document profile constrains Composition to specify a clinical document (matching CDA icon). See also the comparison with CDA.

2.8.2 Boundaries and Relationships

Composition is a structure for grouping information for purposes of persistence and attestability. The Composition resource defines a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. The Composition resource provides the basic structure of a FHIR document. The full content of the document is expressed using a Bundle containing the Composition and its entries.

There are several other grouping structures in FHIR with distinct purposes:

  • The List resource - enumerates a flat collection of resources and provides features for managing the collection. While a particular List instance may represent a "snapshot", from a business process perspective, the notion of "list" is dynamic – items are added and removed over time. The List resource references other resources. Lists may be curated and have specific business meaning.
  • The Group resource - defines a group of specific people, animals, devices, etc. by enumerating them, or by describing qualities that group members have. The Group resource refers to other resources, possibly implicitly. Groups are intended to be acted upon or observed as a whole (e.g., performing therapy on a group, calculating risk for a group, etc.). This resource will commonly be used for public health (e.g., describing an at-risk population), clinical trials (e.g., defining a test subject pool) and similar purposes.
  • The Bundle resource - is an infrastructure container for a group of resources. It does not have narrative and is used to group collections of resources for transmission, persistence or processing (e.g., messages, documents, transactions, query responses, etc.). The content of bundles is typically algorithmically determined for a particular exchange or persistence purpose.
  • The QuestionnaireResponse resource - is similar to Composition in that both organize collections of items and can have a hierarchical structure. Questionnaires are also intended to help guide 'human' presentation of data. However, Compositions organize resources, while Questionnaires/QuestionnaireResponses organize specific elements. Also, a Questionnaire represents data 'to be gathered' and is subject-independent, while Compositions represent collections of data that are complete and are about a particular subject. It is possible for StructureDefinitions or GraphDefinitions to act as 'templates' for FHIR documents that guide what data is collected for a particular purpose (e.g. a referral), but this differs from the gathering process that a Questionnaire provides where there are specific questions that must be asked and answered and rules that guide which questions are enabled in which circumstances.

The Composition resource organizes clinical and administrative content into sections, each of which contains a narrative, and references other resources for supporting data. The narrative content of the various sections in a Composition are supported by the resources referenced in the section entries. The complete set of content to make up a document includes the Composition resource together with various resources pointed to or indirectly connected to the Composition. See the FHIR Documents documentation for guidance on how a Composition is used when creating a document bundle.

2.8.3 Background and Context

2.8.3.1 Composition Status Codes

Every composition has a status element, which describes the status of the content of the composition, taken from this list of codes:

2.8.3.2 The workflow/clinical status of the composition.

registered The existence of the composition is registered, but there is nothing yet available.
partial This is a partial (e.g. initial, interim or preliminary) composition: data in the composition may be incomplete or unverified.
preliminary Verified early results are available, but not all results are final.
final This version of the composition is complete and verified by an appropriate person and no further work is planned. Any subsequent updates would be on a new version of the composition.
amended The composition content or the referenced resources have been modified (edited or added to) subsequent to being released as "final" and the composition is complete and verified by an authorized person.
corrected Subsequent to being final, the composition content has been modified to correct an error in the composition or referenced results.
appended Subsequent to being final, the composition content has been modified by adding new content. The existing content is unchanged.
cancelled The composition is unavailable because the measurement was not started or not completed (also sometimes called "aborted").
entered-in-error The composition or document was originally created/issued in error, and this is an amendment that marks that the entire series should not be considered as valid.
deprecated This composition has been withdrawn or superseded and should no longer be used.
unknown The authoring/source system does not know which of the status values currently applies for this observation. Note: This concept is not to be used for "other" - one of the listed statuses is presumed to apply, but the authoring/source system does not know which.

Composition status generally only moves down through this list - it moves from registered or preliminary to final and then it may progress to amended. Note that in many workflows, only final compositions are made available and the preliminary status is not used.

Diagram showing typical transitions of clinical status for the Composition resource

A very few compositions are created entirely in error in the workflow - usually the composition concerns the wrong patient or is written by the wrong author, and the error is only detected after the composition has been used or documents have been derived from it. To support resolution of this case, the composition is updated to be marked as entered-in-error and a new derived document can be created. This means that the entire series of derived documents is now considered to be created in error and systems receiving derived documents based on retracted compositions SHOULD remove data taken from earlier documents from routine use and/or take other appropriate actions. Systems are not required to provide this workflow or support documents derived from retracted compositions, but they SHALL NOT ignore a status of entered-in-error. Note that systems that handle compositions or derived documents and don't support the error status need to define some other way of handling compositions that are created in error; while this is not a common occurrence, some clinical systems have no provision for removing erroneous information from a patient's record, and there is no way for a user to know that it is not fit for use - this is not safe.

2.8.3.3 Note for CDA aware readers

Many users of this specification are familiar with the Clinical Document Architecture icon (CDA) and related specifications. CDA is a primary design input to the Composition resource (other principal inputs are other HL7 document specifications and EN13606). There are three important structural differences between CDA and the Composition resource:

  • A composition is a logical construct - its identifier matches to the CDA ClinicalDocument.setId. Composition resources are wrapped into Document structures, for exchange of the whole package (the composition and its parts), and this wrapped, sealed entity is equivalent to a CDA document, where the where the Bundle.identifier is equivalent to ClinicalDocument.id and Bundle.meta.security is equivalent to ClinicalDocument.confidentialityCode.
  • The composition section defines a section (or sub-section) of the document, but unlike CDA, the section entries are actually references to other resources that hold the supporting data content for the section. This design means that the data can be reused in many other ways.
  • Unlike CDA, the context defined in the Composition (the subject, author, event, event period and encounter) apply to the composition and do not specifically apply to the resources referenced from the section.entry. There is no context flow model in FHIR, so each resource referenced from within a Composition expresses its own individual context. In this way, clinical content can safely be extracted from the composition.

In addition, note that both the code lists (e.g., Composition.status) and the Composition resource are mapped to HL7 v3 icon and/or CDA.

2.8.4 References to this Resource

2.8.5 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition TU DomainResource A set of resources composed into a single coherent clinical statement with clinical attestation

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... url Σ 0..1 uri Canonical identifier for this Composition, represented as a URI (globally unique)
... identifier Σ 0..* Identifier Version-independent identifier for the Composition

... version Σ 0..1 string An explicitly assigned identifier of a variation of the content in the Composition
... type Σ 1..1 CodeableConcept Kind of composition (LOINC if possible)
Binding: FHIR Document Type Codes (Preferred)
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: Referenced Item Category Value Set (Example)

... subject Σ 0..* Reference(Any) Who and/or what the composition is about

... encounter Σ 0..1 Reference(Encounter) Context of the Composition
... date Σ 1..1 dateTime Composition editing time
... useContext Σ 0..* UsageContext The context that the content is intended to support

... author Σ 1..* Reference(Practitioner | PractitionerRole | CareTeam | Device | Patient | RelatedPerson | Organization) Who and/or what authored the composition

... name Σ 0..1 string Name for this Composition (computer friendly)
... title Σ 1..1 string Human Readable name/title
... note 0..* Annotation For any additional notes

... attester 0..* BackboneElement Attests to accuracy of composition

.... mode 1..1 CodeableConcept personal | professional | legal | official
Binding: Composition Attestation Mode (Preferred)
.... 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..* RelatedArtifact Relationships to other compositions/documents

... event Σ 0..* BackboneElement The clinical service(s) being documented

.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* CodeableReference(Any) The event(s) being documented, as code(s), reference(s), or both
Binding: v3 Code System ActCode icon (Example)

... section C 0..* BackboneElement Composition is broken into sections
+ Rule: A section must contain at least one of text, entries, or sub-sections
+ Rule: A section can only have an emptyReason if no entries are included

.... title 0..1 string Label for section (e.g. for ToC)
.... code 0..1 CodeableConcept Classification of section (recommended)
Binding: Document Section Codes (Example)
.... author 0..* Reference(Practitioner | PractitionerRole | CareTeam | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section, when the section is authored by someone other than the composition.author

.... focus 0..1 Reference(Any) 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
.... orderedBy 0..1 CodeableConcept Order of section entries
Binding: List Order Codes (Preferred)
.... entry C 0..* Reference(Any) A reference to data that supports this section

.... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: List Empty Reasons (Preferred)
.... section 0..* see section Nested Section


doco Documentation for this format icon

See the Extensions for this resource

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

2.8.5.1 Terminology Bindings

Path ValueSet Type Documentation
Composition.status CompositionStatus Required

The workflow/clinical status of the composition.
Composition.type FHIRDocumentTypeCodes Preferred

FHIR Document Codes - all LOINC codes where scale type = 'DOC'.
Composition.category ReferencedItemCategoryValueSet Example

This is the code specifying the high-level kind of document (e.g. Prescription, Discharge Summary, Report, etc.). Made up of a set of non-healthcare specific codes and all LOINC codes where scale type = 'DOC'.
Composition.attester.mode CompositionAttestationMode Preferred

The way in which a person authenticated a composition.
Composition.event.detail ActCode icon Example

A code specifying the particular kind of Act that the Act-instance represents within its class. Constraints: The kind of Act (e.g. physical examination, serum potassium, inpatient encounter, charge financial transaction, etc.) is specified with a code from one of several, typically external, coding systems. The coding system will depend on the class of Act, such as LOINC for observations, etc. Conceptually, the Act.code must be a specialization of the Act.classCode. This is why the structure of ActClass domain should be reflected in the superstructure of the ActCode domain and then individual codes or externally referenced vocabularies subordinated under these domains that reflect the ActClass structure. Act.classCode and Act.code are not modifiers of each other but the Act.code concept should really imply the Act.classCode concept. For a negative example, it is not appropriate to use an Act.code "potassium" together with and Act.classCode for "laboratory observation" to somehow mean "potassium laboratory observation" and then use the same Act.code for "potassium" together with Act.classCode for "medication" to mean "substitution of potassium". This mutually modifying use of Act.code and Act.classCode is not permitted.
Composition.section.code DocumentSectionCodes Example

Document section codes (LOINC codes used in CCDA sections).
Composition.section.orderedBy ListOrderCodes Preferred

Base values for the order of the items in a list resource.
Composition.section.emptyReason ListEmptyReasons Preferred

General reasons for a list to be empty. Reasons are either related to a summary list (i.e. problem or medication list) or to a workflow related list (i.e. consultation list).

2.8.5.2 Constraints

UniqueKeyLevelLocationDescriptionExpression
img cmp-1Rule Composition.sectionA section must contain at least one of text, entries, or sub-sectionstext.exists() or entry.exists() or section.exists()
img cmp-2Rule Composition.sectionA section can only have an emptyReason if no entries are includedemptyReason.empty() or entry.empty()

2.8.6 Notes:

  • The author and the attester are often the same person, but this might not be the case in some clinical workflows.
  • The attester attests contents of the document resource, the subject resource and the resources referred to in the Composition.section.content references. Because documents are often derived Compositions and the attestation from the composition is held to apply to the document, the method for presenting a document should be used when/if attesters review the content of the composition.
  • The custodian is responsible for the maintenance of the composition and any documents derived from it. With regard to the documents, they are responsible for the policy regarding persistence of the documents. Although they need not actually retain a copy of the document, they SHOULD do so.
  • It is acceptable for a Composition to contain only narrative (Composition.section.text) and no entries (Composition.section.entry)

2.8.7 Compositions about multiple entities

Typically, a composition is made about the subject - e.g. a patient, or group of patients, location, or device - and the distinction between the subject and the composition describes the subject. Some kinds of documents contain data about other parties or entities that are relevant to the subject of the document. Some examples:

  • A neonatal discharge summary that contains information about the mother
  • A family history document that contains multiple sections for different family members
  • A social health evaluation document that contains information about the patient's family members
  • A procedure report that contains details about a device implanted in the patient

In all these cases, the subject of the document is a single patient, but some of the details are actually related to other persons or entities. When this happens, these other entities are detailed in the Composition.section.focus element. In the absence of a focus, it is assumed that the subject of the composition is the focus.

If a focus is specified, then the resources referred to from the section SHALL either:

  • specify that their subject (however named e.g. patient) or focus element (if present) is the focus indicated
  • not have a subject element

A few compositions genuinely cover multiple subjects - different sections are about different subjects. In such case, Composition.subject is omitted, and the extension section-subject is used on each section to indicate the subject.

Note to Implementers: Feedback is welcome on two issues related to Composition:

  • For many compositions, the title is the same as the text or a display name of Composition.type (e.g., a "consultation" or "progress note"). Note that CDA icon does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here during the trial use period.
  • A client can ask a server to generate a fully bundled document from a Composition resource using the $document operation. This operation definition does not resolve the question how document signatures are created. This is an open issue during the period of trial use, and feedback is requested regarding this question.

Feedback here icon.

2.8.8 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
attester reference Who attested the composition Composition.attester.party
(Practitioner, Organization, Patient, PractitionerRole, RelatedPerson)
author reference Who and/or what authored the composition Composition.author
(Practitioner, Organization, CareTeam, Device, Patient, PractitionerRole, RelatedPerson)
category token Categorization of Composition Composition.category
date date Composition editing time Composition.date 26 Resources
encounter reference Context of the Composition Composition.encounter
(Encounter)		 29 Resources
entry reference A reference to data that supports this section Composition.section.entry
(Any)
event-code token Main clinical acts documented as codes Composition.event.detail.concept
event-reference reference Main clinical acts documented as references Composition.event.detail.reference
identifier token Version-independent identifier for the Composition Composition.identifier 65 Resources
patient reference Who and/or what the composition is about Composition.subject.where(resolve() is Patient)
(Patient)		 65 Resources
period date The period covered by the documentation Composition.event.period
related reference Target of the relationship Composition.relatesTo.resourceReference
(Any)
section token Classification of section (recommended) Composition.section.code
section-code-text composite Search on the section narrative of the resource On Composition.section:
  section: section.code
  section-text: section.text
section-text special Search on the section narrative of the resource Composition.section.text | Composition.section.section.text
status token preliminary | final | amended | entered-in-error Composition.status
subject reference Who and/or what the composition is about Composition.subject
(Any)
title string Human Readable name/title Composition.title
type token Kind of composition (LOINC if possible) Composition.type 11 Resources
url uri The uri that identifies the activity definition Composition.url
version token The business version of the activity definition Composition.version