Australian Digital Health Agency FHIR Implementation Guide

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

Where a more specific document Composition profile is applicable, e.g. shared health summary, an implementation SHALL ensure the resource conforms to that specific profile.

This profile supports the equivalent of all HL7 CDA conformance levels for a clinical document as defined in the Agency's Common Conformance Profile for Clinical Documents.

This profile is designed to set a Composition standard for:

• exchanging a FHIR Document
• Query for a document for a patient
• Record or update a document record for a patient

Profile specific guidance

None.

Boundaries and relationships

These profiles build on this profile (ADHA Document Composition) to define specific document compositions:

• ADHA Advance Care Directive Custodian Record Composition
• ADHA Advance Care Planning Composition
• ADHA Continuity of Care Summary Composition
• ADHA Discharge Summary Composition
• ADHA Diagnostic Report Composition
• ADHA Event Summary Composition
• ADHA Event Summary Mixed Narrative and Structure
• ADHA Event Summary Narrative
• ADHA Medicare Overview Composition
• ADHA National Cancer Screening Program Participation View
• ADHA Personal Health Notes Composition
• ADHA Personal Health Summary Composition
• ADHA Personal Observations Composition
• ADHA Prescription and or Dispense History Composition
• ADHA Shared Health Summary Composition
• ADHA Shared Medicines List Composition

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from AUBaseComposition

Name	Flags	Card.	Type	Description & Constraints
Composition	C	0..*	AUBaseComposition	Composition for the Australian realm 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
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
identifier	S	1..1	Identifier	Version-independent identifier for the Composition
status	S	1..1	code	preliminary | final | amended | entered-in-error
type	S	1..1	CodeableConcept	Document sub type Binding: My Health Record Record Type (extensible)
category	S	1..*	CodeableConcept	Categorization of Composition Binding: My Health Record Record Class (extensible)
subject	SC	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	S	0..1	Reference(ADHA Core Encounter)	Context of the Composition
date	SC	1..1	dateTime	Composition editing time inv-dh-doc-07: Date shall be at least to day
author	SC	1..*	Reference(ADHA Authoring PractitionerRole | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson)	Who and/or what authored the composition inv-dh-doc-04: At least reference or a valid identifier shall be present
title	S	1..1	string	Human Readable name/title
confidentiality		0..0
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
mode	S	1..1	code	personal | professional | legal | official
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	SC	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
code	S	1..1	code	replaces | transforms | signs | appends
target[x]	S	1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(ADHA Core Composition)
section	S	1..*	BackboneElement	Composition is broken into sections
title	S	0..1	string	Label for section (e.g. for ToC)
code	S	0..1	CodeableConcept	Classification of section (recommended)
text	S	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Fixed Value: snapshot
entry	S	0..*	Reference(Resource)	A reference to data that supports this section
reference		1..1	string	Literal reference, Relative, internal or absolute URL
emptyReason	S	0..1	CodeableConcept	Why the section is empty
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.type	extensible	MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 from https://tx.ontoserver.csiro.au/fhir
Composition.category	extensible	MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 from https://tx.ontoserver.csiro.au/fhir

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-doc-01	error	Composition	If present, an information recipient shall at least have a reference, an identifier or a display : informationRecipient.exists() implies informationRecipient.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-doc-02	error	Composition	Sections shall be unique by code : section.select(code.coding.code).isDistinct()
inv-dh-doc-03	error	Composition.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-04	error	Composition.author	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-05	error	Composition.attester	The party shall at least have a reference or a valid identifier : party.reference.exists() or party.identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-06	error	Composition.custodian	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-07	error	Composition.date	Date shall be at least to day : toString().length() >= 10

Name	Flags	Card.	Type	Description & Constraints
Composition	C	0..*	AUBaseComposition	Composition for the Australian realm dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management 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 ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
informationRecipient	SC	0..*	Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization)	Information recipient URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	SΣ	1..1	Identifier	Version-independent identifier for the Composition ele-1: All FHIR elements must have a @value or children
status	?!SΣ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children
type	SΣ	1..1	CodeableConcept	Document sub type Binding: My Health Record Record Type (extensible) ele-1: All FHIR elements must have a @value or children
category	SΣ	1..*	CodeableConcept	Categorization of Composition Binding: My Health Record Record Class (extensible) ele-1: All FHIR elements must have a @value or children
subject	SΣC	1..1	Reference(ADHA Core Patient)	Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children
date	SΣC	1..1	dateTime	Composition editing time ele-1: All FHIR elements must have a @value or children inv-dh-doc-07: Date shall be at least to day
author	SΣC	1..*	Reference(ADHA Authoring PractitionerRole | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson)	Who and/or what authored the composition ele-1: All FHIR elements must have a @value or children inv-dh-doc-04: At least reference or a valid identifier shall be present
title	SΣ	1..1	string	Human Readable name/title ele-1: All FHIR elements must have a @value or children
attester	SC	0..*	BackboneElement	Attests to accuracy of composition ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
mode	S	1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children
time	S	1..1	dateTime	When the composition was attested ele-1: All FHIR elements must have a @value or children
party	SC	1..1	Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Core Organization)	Who attested the composition ele-1: All FHIR elements must have a @value or children
custodian	SΣC	1..1	Reference(ADHA Core Organization)	Organization which maintains the composition ele-1: All FHIR elements must have a @value or children inv-dh-doc-06: At least reference or a valid identifier shall be present
relatesTo	S	0..*	BackboneElement	Relationships to other compositions/documents ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
code	S	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. ele-1: All FHIR elements must have a @value or children
target[x]	S	1..1		Target of the relationship ele-1: All FHIR elements must have a @value or children
targetIdentifier			Identifier
targetReference			Reference(ADHA Core Composition)
section	SC	1..*	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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	0..1	string	Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children
code	S	0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children
text	SC	0..1	Narrative	Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. ele-1: All FHIR elements must have a @value or children Fixed Value: snapshot
entry	SC	0..*	Reference(Resource)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
emptyReason	SC	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 from https://tx.ontoserver.csiro.au/fhir
Composition.category	extensible	MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 from https://tx.ontoserver.csiro.au/fhir
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section.mode	required	Fixed Value: snapshot http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-doc-01	error	Composition	If present, an information recipient shall at least have a reference, an identifier or a display : informationRecipient.exists() implies informationRecipient.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-doc-02	error	Composition	Sections shall be unique by code : section.select(code.coding.code).isDistinct()
inv-dh-doc-03	error	Composition.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-04	error	Composition.author	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-05	error	Composition.attester	The party shall at least have a reference or a valid identifier : party.reference.exists() or party.identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-06	error	Composition.custodian	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-07	error	Composition.date	Date shall be at least to day : toString().length() >= 10

Name	Flags	Card.	Type	Description & Constraints
Composition	C	0..*	AUBaseComposition	Composition for the Australian realm 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
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
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.
type	SΣ	1..1	CodeableConcept	Document sub type Binding: My Health Record Record Type (extensible)
category	SΣ	1..*	CodeableConcept	Categorization of Composition Binding: My Health Record Record Class (extensible)
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..*	Reference(ADHA Authoring PractitionerRole | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson)	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..*	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	S	0..1	string	Label for section (e.g. for ToC)
code	S	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	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.
entry	SC	0..*	Reference(Resource)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
emptyReason	SC	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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 from https://tx.ontoserver.csiro.au/fhir
Composition.category	extensible	MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 from https://tx.ontoserver.csiro.au/fhir
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.event.code	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section.mode	required	Fixed Value: snapshot http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.entry.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-doc-01	error	Composition	If present, an information recipient shall at least have a reference, an identifier or a display : informationRecipient.exists() implies informationRecipient.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-doc-02	error	Composition	Sections shall be unique by code : section.select(code.coding.code).isDistinct()
inv-dh-doc-03	error	Composition.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-04	error	Composition.author	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-05	error	Composition.attester	The party shall at least have a reference or a valid identifier : party.reference.exists() or party.identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-06	error	Composition.custodian	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-07	error	Composition.date	Date shall be at least to day : toString().length() >= 10

Differential View

This structure is derived from AUBaseComposition

Name	Flags	Card.	Type	Description & Constraints
Composition	C	0..*	AUBaseComposition	Composition for the Australian realm 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
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
identifier	S	1..1	Identifier	Version-independent identifier for the Composition
status	S	1..1	code	preliminary | final | amended | entered-in-error
type	S	1..1	CodeableConcept	Document sub type Binding: My Health Record Record Type (extensible)
category	S	1..*	CodeableConcept	Categorization of Composition Binding: My Health Record Record Class (extensible)
subject	SC	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	S	0..1	Reference(ADHA Core Encounter)	Context of the Composition
date	SC	1..1	dateTime	Composition editing time inv-dh-doc-07: Date shall be at least to day
author	SC	1..*	Reference(ADHA Authoring PractitionerRole | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson)	Who and/or what authored the composition inv-dh-doc-04: At least reference or a valid identifier shall be present
title	S	1..1	string	Human Readable name/title
confidentiality		0..0
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
mode	S	1..1	code	personal | professional | legal | official
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	SC	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
code	S	1..1	code	replaces | transforms | signs | appends
target[x]	S	1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(ADHA Core Composition)
section	S	1..*	BackboneElement	Composition is broken into sections
title	S	0..1	string	Label for section (e.g. for ToC)
code	S	0..1	CodeableConcept	Classification of section (recommended)
text	S	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Fixed Value: snapshot
entry	S	0..*	Reference(Resource)	A reference to data that supports this section
reference		1..1	string	Literal reference, Relative, internal or absolute URL
emptyReason	S	0..1	CodeableConcept	Why the section is empty
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.type	extensible	MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 from https://tx.ontoserver.csiro.au/fhir
Composition.category	extensible	MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 from https://tx.ontoserver.csiro.au/fhir

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-doc-01	error	Composition	If present, an information recipient shall at least have a reference, an identifier or a display : informationRecipient.exists() implies informationRecipient.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-doc-02	error	Composition	Sections shall be unique by code : section.select(code.coding.code).isDistinct()
inv-dh-doc-03	error	Composition.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-04	error	Composition.author	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-05	error	Composition.attester	The party shall at least have a reference or a valid identifier : party.reference.exists() or party.identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-06	error	Composition.custodian	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-07	error	Composition.date	Date shall be at least to day : toString().length() >= 10

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Composition	C	0..*	AUBaseComposition	Composition for the Australian realm dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management 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 ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
informationRecipient	SC	0..*	Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization)	Information recipient URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	SΣ	1..1	Identifier	Version-independent identifier for the Composition ele-1: All FHIR elements must have a @value or children
status	?!SΣ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children
type	SΣ	1..1	CodeableConcept	Document sub type Binding: My Health Record Record Type (extensible) ele-1: All FHIR elements must have a @value or children
category	SΣ	1..*	CodeableConcept	Categorization of Composition Binding: My Health Record Record Class (extensible) ele-1: All FHIR elements must have a @value or children
subject	SΣC	1..1	Reference(ADHA Core Patient)	Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children
date	SΣC	1..1	dateTime	Composition editing time ele-1: All FHIR elements must have a @value or children inv-dh-doc-07: Date shall be at least to day
author	SΣC	1..*	Reference(ADHA Authoring PractitionerRole | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson)	Who and/or what authored the composition ele-1: All FHIR elements must have a @value or children inv-dh-doc-04: At least reference or a valid identifier shall be present
title	SΣ	1..1	string	Human Readable name/title ele-1: All FHIR elements must have a @value or children
attester	SC	0..*	BackboneElement	Attests to accuracy of composition ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
mode	S	1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children
time	S	1..1	dateTime	When the composition was attested ele-1: All FHIR elements must have a @value or children
party	SC	1..1	Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Core Organization)	Who attested the composition ele-1: All FHIR elements must have a @value or children
custodian	SΣC	1..1	Reference(ADHA Core Organization)	Organization which maintains the composition ele-1: All FHIR elements must have a @value or children inv-dh-doc-06: At least reference or a valid identifier shall be present
relatesTo	S	0..*	BackboneElement	Relationships to other compositions/documents ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
code	S	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. ele-1: All FHIR elements must have a @value or children
target[x]	S	1..1		Target of the relationship ele-1: All FHIR elements must have a @value or children
targetIdentifier			Identifier
targetReference			Reference(ADHA Core Composition)
section	SC	1..*	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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
title	S	0..1	string	Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children
code	S	0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children
text	SC	0..1	Narrative	Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. ele-1: All FHIR elements must have a @value or children Fixed Value: snapshot
entry	SC	0..*	Reference(Resource)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
emptyReason	SC	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 from https://tx.ontoserver.csiro.au/fhir
Composition.category	extensible	MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 from https://tx.ontoserver.csiro.au/fhir
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section.mode	required	Fixed Value: snapshot http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-doc-01	error	Composition	If present, an information recipient shall at least have a reference, an identifier or a display : informationRecipient.exists() implies informationRecipient.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-doc-02	error	Composition	Sections shall be unique by code : section.select(code.coding.code).isDistinct()
inv-dh-doc-03	error	Composition.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-04	error	Composition.author	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-05	error	Composition.attester	The party shall at least have a reference or a valid identifier : party.reference.exists() or party.identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-06	error	Composition.custodian	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-07	error	Composition.date	Date shall be at least to day : toString().length() >= 10

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Composition	C	0..*	AUBaseComposition	Composition for the Australian realm 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
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
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.
type	SΣ	1..1	CodeableConcept	Document sub type Binding: My Health Record Record Type (extensible)
category	SΣ	1..*	CodeableConcept	Categorization of Composition Binding: My Health Record Record Class (extensible)
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..*	Reference(ADHA Authoring PractitionerRole | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson)	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..*	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	S	0..1	string	Label for section (e.g. for ToC)
code	S	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	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.
entry	SC	0..*	Reference(Resource)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
emptyReason	SC	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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 from https://tx.ontoserver.csiro.au/fhir
Composition.category	extensible	MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 from https://tx.ontoserver.csiro.au/fhir
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.event.code	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section.mode	required	Fixed Value: snapshot http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.entry.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-doc-01	error	Composition	If present, an information recipient shall at least have a reference, an identifier or a display : informationRecipient.exists() implies informationRecipient.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-doc-02	error	Composition	Sections shall be unique by code : section.select(code.coding.code).isDistinct()
inv-dh-doc-03	error	Composition.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-04	error	Composition.author	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-05	error	Composition.attester	The party shall at least have a reference or a valid identifier : party.reference.exists() or party.identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-06	error	Composition.custodian	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-07	error	Composition.date	Date shall be at least to day : toString().length() >= 10

This structure is derived from AUBaseComposition

Summary

Mandatory: 5 elements(3 nested mandatory elements)
Must-Support: 24 elements
Fixed: 1 element
Prohibited: 1 element

Structures

This structure refers to these other structures:

• ADHA Core Patient (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-patient-core-1)
• ADHA Core Encounter (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-encounter-core-1)
• ADHA Authoring PractitionerRole (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-practitionerrole-author-1)
• ADHA System Device (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-device-system-1)
• ADHA Authoring RelatedPerson (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-relatedperson-author-1)
• ADHA Core Organization (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-organization-core-1)
• ADHA Core Composition (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-composition-core-1)

Extensions

This structure refers to these extensions:

• http://hl7.org.au/fhir/StructureDefinition/information-recipient

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.

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=http://loinc.org|18842-5
   

   Implementation Notes: Fetches a bundle of all Composition resources with the category of "Discharge summary" 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=http://loinc.org|18842-5
   

   Implementation Notes: Fetches a bundle of all Composition resources with the type of an 18842-5 (Discharge summary) 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)