Australian Digital Health Agency FHIR Implementation Guide
1.2.0-ci-build - draft
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-phn-1 | Version: 0.0.3 | |||
| Draft as of 2024-09-12 | Computable Name: ADHACompositionPHN | |||
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/. |
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The purpose of this profile is to define a representation of a Personal Health Notes document for a patient 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.
Due to the nature of this document type with a single narrative only section, this profile supports the equivalent of a HL7 CDA instance conformance Level 1B, Level 2, Level 3A and 3B clinical document as defined in the Agency's Common Conformance Profile for Clinical Documents.
This profile is designed to set a Composition standard for:
This profile may be referred to by APIs, which will be listed here when available.
None.
This profile is not referenced by another profile in this implementation guide.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ADHACompositionDocument
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition |
0..* | ADHACompositionDocument | Personal Health Notes | |
  status |
1..1 | code | preliminary | final | amended | entered-in-error Required Pattern: final | |
 type |
1..1 | CodeableConcept | Document sub type Required Pattern: At least the following | |
   coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
 system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
 code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51855-5 | |
 Slices for category |
1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this | |
  category:phn |
1..1 | CodeableConcept | Personal Health Notes Required Pattern: At least the following | |
 coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1 | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.16681 | |
 author |
1..1 | Reference(ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Authoring Care Agency Employee) | Who and/or what authored the composition | |
| section |
1..1 | BackboneElement | Notes | |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51855-5 | |
| entry |
0..0 | |||
| emptyReason |
0..0 | |||
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
C | 0..* | ADHACompositionDocument | Personal Health Notes 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 |
Content/Rules for all slices | |||
 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. Required Pattern: final |
| type |
SΣ | 1..1 | CodeableConcept | Document sub type Binding: My Health Record Record Type  (extensible)Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51855-5 | |
| Slices for category |
SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this Binding: My Health Record Record Class (extensible) |
| category:phn |
SΣ | 1..1 | CodeableConcept | Personal Health Notes Binding: My Health Record Record Class (extensible)Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1 | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.16681 | |
| 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..1 | Reference(ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Authoring Care Agency Employee) | 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..1 | BackboneElement | Notes 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51855-5 | |
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Composition.status | required | Pattern: finalhttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | |
| Composition.type | extensible | Pattern: LOINC Code 51855-5https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 | |
| Composition.category | extensible | MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 | |
| Composition.category:phn | extensible | Pattern: 100.16681https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 | |
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | |
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | |
| Composition.section.code | example | Pattern: LOINC Code 51855-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
C | 0..* | ADHACompositionDocument | Personal Health Notes 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. Required Pattern: final | ||||
| type |
SΣ | 1..1 | CodeableConcept | Document sub type Binding: My Health Record Record Type (extensible)Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51855-5 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| Slices for category |
SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this Binding: My Health Record Record Class (extensible) | ||||
| category:phn |
SΣ | 1..1 | CodeableConcept | Personal Health Notes Binding: My Health Record Record Class (extensible)Required Pattern: At least the following | ||||
 id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
 coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
 id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1 | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.16681 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
 text |
0..1 | string | Plain text representation of the concept | |||||
| 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..1 | Reference(ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Authoring Care Agency Employee) | 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..1 | BackboneElement | Notes 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51855-5 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| 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. | |||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | Pattern: finalhttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | extensible | Pattern: LOINC Code 51855-5https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 | ||||
| Composition.category | extensible | MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 | ||||
| Composition.category:phn | extensible | Pattern: 100.16681https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | Pattern: LOINC Code 51855-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | Fixed Value: snapshothttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.entry.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard |
This structure is derived from ADHACompositionDocument
Summary
Mandatory: 2 elements
Prohibited: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from ADHACompositionDocument
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | ADHACompositionDocument | Personal Health Notes | |
| status |
1..1 | code | preliminary | final | amended | entered-in-error Required Pattern: final | |
| type |
1..1 | CodeableConcept | Document sub type Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51855-5 | |
| Slices for category |
1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this | |
| category:phn |
1..1 | CodeableConcept | Personal Health Notes Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1 | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.16681 | |
| author |
1..1 | Reference(ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Authoring Care Agency Employee) | Who and/or what authored the composition | |
| section |
1..1 | BackboneElement | Notes | |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51855-5 | |
| entry |
0..0 | |||
| emptyReason |
0..0 | |||
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
C | 0..* | ADHACompositionDocument | Personal Health Notes 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 |
Content/Rules for all slices | |||
| 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. Required Pattern: final |
| type |
SΣ | 1..1 | CodeableConcept | Document sub type Binding: My Health Record Record Type (extensible)Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51855-5 | |
| Slices for category |
SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this Binding: My Health Record Record Class (extensible) |
| category:phn |
SΣ | 1..1 | CodeableConcept | Personal Health Notes Binding: My Health Record Record Class (extensible)Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1 | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.16681 | |
| 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..1 | Reference(ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Authoring Care Agency Employee) | 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..1 | BackboneElement | Notes 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51855-5 | |
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Composition.status | required | Pattern: finalhttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | |
| Composition.type | extensible | Pattern: LOINC Code 51855-5https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 | |
| Composition.category | extensible | MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 | |
| Composition.category:phn | extensible | Pattern: 100.16681https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 | |
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | |
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | |
| Composition.section.code | example | Pattern: LOINC Code 51855-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
C | 0..* | ADHACompositionDocument | Personal Health Notes 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. Required Pattern: final | ||||
| type |
SΣ | 1..1 | CodeableConcept | Document sub type Binding: My Health Record Record Type (extensible)Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51855-5 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| Slices for category |
SΣ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by pattern:$this Binding: My Health Record Record Class (extensible) | ||||
| category:phn |
SΣ | 1..1 | CodeableConcept | Personal Health Notes Binding: My Health Record Record Class (extensible)Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1 | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.16681 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| 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..1 | Reference(ADHA Core Patient | ADHA Authoring RelatedPerson | ADHA Authoring Care Agency Employee) | 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..1 | BackboneElement | Notes 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 | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 51855-5 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| 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. | |||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Composition.status | required | Pattern: finalhttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | extensible | Pattern: LOINC Code 51855-5https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 | ||||
| Composition.category | extensible | MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 | ||||
| Composition.category:phn | extensible | Pattern: 100.16681https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | Pattern: LOINC Code 51855-5http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | Fixed Value: snapshothttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.entry.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard |
This structure is derived from ADHACompositionDocument
Summary
Mandatory: 2 elements
Prohibited: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
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=https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1|100.16681
Implementation Notes: Fetches a bundle of all Composition resources with the category of "Personal Health Notes" 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=https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1|100.16681
Implementation Notes: Fetches a bundle of all Composition resources with the type of an 100.16681 (Personal Health Notes) 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)
IG © 2023+ Australian Digital Health Agency. Package au.digitalhealth.r4#1.2.0-ci-build based on FHIR 4.0.1. Generated 2024-09-12
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