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

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

Resource Profile: ADHA Document Composition

Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-composition-document-1 Version: 0.0.6
Draft as of 2024-09-12 Computable Name: ADHACompositionDocument

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

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

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

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:

Usage:

Formal Views of Profile Content

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

This structure is derived from AUBaseComposition

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.typeextensibleMyHealthRecordRecordType .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1
Composition.categoryextensibleMyHealthRecordRecordClass .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-doc-01errorCompositionIf 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-02errorCompositionSections shall be unique by code
: section.select(code.coding.code).isDistinct()
inv-dh-doc-03errorComposition.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-04errorComposition.authorAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-05errorComposition.attesterThe 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-06errorComposition.custodianAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-07errorComposition.dateDate shall be at least to day
: toString().length() >= 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... informationRecipient SC 0..* Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) Information recipient
URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... 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
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode S 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

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

.... target[x] S 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(ADHA Core Composition)
... section SC 1..* 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
.... 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.

.... 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
.... entry SC 0..* Reference(Resource) A reference to data that supports this section
..... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typeextensibleMyHealthRecordRecordType .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1
Composition.categoryextensibleMyHealthRecordRecordClass .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredFixed Value: snapshot
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-doc-01errorCompositionIf 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-02errorCompositionSections shall be unique by code
: section.select(code.coding.code).isDistinct()
inv-dh-doc-03errorComposition.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-04errorComposition.authorAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-05errorComposition.attesterThe 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-06errorComposition.custodianAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-07errorComposition.dateDate shall be at least to day
: toString().length() >= 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typeextensibleMyHealthRecordRecordType .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1
Composition.categoryextensibleMyHealthRecordRecordClass .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredFixed Value: snapshot
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-doc-01errorCompositionIf 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-02errorCompositionSections shall be unique by code
: section.select(code.coding.code).isDistinct()
inv-dh-doc-03errorComposition.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-04errorComposition.authorAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-05errorComposition.attesterThe 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-06errorComposition.custodianAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-07errorComposition.dateDate shall be at least to day
: toString().length() >= 10

Differential View

This structure is derived from AUBaseComposition

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Composition.typeextensibleMyHealthRecordRecordType .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1
Composition.categoryextensibleMyHealthRecordRecordClass .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-doc-01errorCompositionIf 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-02errorCompositionSections shall be unique by code
: section.select(code.coding.code).isDistinct()
inv-dh-doc-03errorComposition.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-04errorComposition.authorAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-05errorComposition.attesterThe 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-06errorComposition.custodianAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-07errorComposition.dateDate shall be at least to day
: toString().length() >= 10

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... informationRecipient SC 0..* Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization) Information recipient
URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... 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
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode S 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

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

.... target[x] S 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(ADHA Core Composition)
... section SC 1..* 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
.... 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.

.... 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
.... entry SC 0..* Reference(Resource) A reference to data that supports this section
..... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... emptyReason SC 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typeextensibleMyHealthRecordRecordType .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1
Composition.categoryextensibleMyHealthRecordRecordClass .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredFixed Value: snapshot
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-doc-01errorCompositionIf 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-02errorCompositionSections shall be unique by code
: section.select(code.coding.code).isDistinct()
inv-dh-doc-03errorComposition.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-04errorComposition.authorAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-05errorComposition.attesterThe 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-06errorComposition.custodianAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-07errorComposition.dateDate shall be at least to day
: toString().length() >= 10

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
Composition.typeextensibleMyHealthRecordRecordType .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1
Composition.categoryextensibleMyHealthRecordRecordClass .
https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
from the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
from the FHIR Standard
Composition.section.moderequiredFixed Value: snapshot
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
from the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
from the FHIR Standard
Composition.section.entry.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-doc-01errorCompositionIf 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-02errorCompositionSections shall be unique by code
: section.select(code.coding.code).isDistinct()
inv-dh-doc-03errorComposition.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-04errorComposition.authorAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-05errorComposition.attesterThe 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-06errorComposition.custodianAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-doc-07errorComposition.dateDate shall be at least to day
: toString().length() >= 10

 

Other representations of profile: CSV, Excel, Schematron

Notes:

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

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

Mandatory Search Parameters

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

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

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

    Example:

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

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

  2. SHALL support searching using the identifier search parameter:

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

    Example:

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

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

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

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

    Example:

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