Australian Digital Health Agency FHIR Implementation Guide
1.2.0-ci-build - draft
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
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:
None.
These profiles build on this profile (ADHA Document Composition) to define specific document compositions:
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
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 |
Path | Conformance | ValueSet | URI |
Composition.type | extensible | MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 | |
Composition.category | extensible | MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 |
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 |
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 |
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 |
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. |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://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 | |
Composition.category | extensible | MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | |
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section.mode | required | Fixed Value: snapshothttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
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.
| |||||
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 |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://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 | ||||
Composition.category | extensible | MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | Fixed Value: snapshothttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.entry.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
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:
Extensions
This structure refers to these extensions:
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 |
Path | Conformance | ValueSet | URI |
Composition.type | extensible | MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 | |
Composition.category | extensible | MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 |
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 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 |
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 |
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. |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://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 | |
Composition.category | extensible | MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | |
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section.mode | required | Fixed Value: snapshothttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | |
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
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.
| |||||
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 |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Composition.status | required | CompositionStatushttp://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 | ||||
Composition.category | extensible | MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | Fixed Value: snapshothttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.entry.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
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:
Extensions
This structure refers to these extensions:
Other representations of profile: CSV, Excel, Schematron
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 |
The following search parameters and search parameter combinations SHALL be supported:
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)
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)
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)
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)
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)