C-CDA on FHIR
2.0.0-ballot - STU 2 Ballot United States of America flag

C-CDA on FHIR, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/ccda-on-fhir/ and changes regularly. See the Directory of published versions

Resource Profile: US Realm Header ( Abstract )

Official URL: http://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header Version: 2.0.0-ballot
Standards status: Trial-use Computable Name: USRealmHeader

This profile defines constraints that represent common administrative and demographic concepts for US Realm clinical documents. Further specification, such as type, are provided in document profiles that conform to this profile.

2025 Ballot of C-CDA ↔ FHIR US Core Mapping

The current release of this IG adds relevant mapping content from C-CDA ↔ FHIR mapping project which was related to the original C-CDA on FHIR work. These mappings are included under the "Mapping" heading and will undergo future updates for additional content.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Clinical Document This is an abstract profile. Child profiles: CarePlan, ConsultationNote, ContinuityOfCareDocument, DiagnosticImagingReport, DischargeSummary, HistoryAndPhysical, OperativeNote, ProcedureNote, ProgressNote, ReferralNote, TransferSummary
A set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language S 1..1 code language
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... Slices for extension Content/Rules for all slices
.... extension:versionNumber 0..* string Version-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:version_number_extension S 0..1 integer Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
.... extension:data_enterer_extension S 0..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
.... extension:informant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
.... extension:information_recipient_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
.... extension:participant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
.... extension:performer_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
.... extension:authorization_extension S 0..* Reference(Consent) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
.... extension:order_extension S 0..* Reference(ServiceRequest) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... identifier SΣ 1..1 Identifier identifier
... status ?!Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type SΣ 1..1 CodeableConcept Kind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
... subject SΣ 0..1 Reference(US Core Patient Profile | Group) Who and/or what the composition is about
... encounter SΣ 0..1 Reference(US Core Encounter Profile) Context of the Composition
... date SΣ 1..1 dateTime date
... author SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) Who and/or what authored the composition
... title SΣ 1..1 string Document Title
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... attester:legal_attester S 0..1 BackboneElement attester
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: legal
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:professional_attester S 0..* BackboneElement attester
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: professional
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:personal_attester S 0..* BackboneElement attester
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: personal
..... party S 1..1 Reference(US Core Patient Profile | RelatedPerson) party
... custodian SΣ 1..1 Reference(US Core Organization Profile) custodian

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
From the FHIR Standard
Composition.typepreferredFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
From the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:legal_attester.moderequiredFixed Value: legal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:professional_attester.moderequiredFixed Value: professional
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:personal_attester.moderequiredFixed Value: personal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Clinical Document

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Clinical Document This is an abstract profile. Child profiles: CarePlan, ConsultationNote, ContinuityOfCareDocument, DiagnosticImagingReport, DischargeSummary, HistoryAndPhysical, OperativeNote, ProcedureNote, ProgressNote, ReferralNote, TransferSummary
A set of resources composed into a single coherent clinical statement with clinical attestation
... language S 1..1 code language
... Slices for extension Content/Rules for all slices
.... extension:version_number_extension S 0..1 integer Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
.... extension:data_enterer_extension S 0..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
.... extension:informant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
.... extension:information_recipient_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
.... extension:participant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
.... extension:performer_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
.... extension:authorization_extension S 0..* Reference(Consent) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
.... extension:order_extension S 0..* Reference(ServiceRequest) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... identifier S 1..1 Identifier identifier
... subject S 0..1 Reference(US Core Patient Profile | Group) Who and/or what the composition is about
... encounter S 0..1 Reference(US Core Encounter Profile) Context of the Composition
... date S 1..1 dateTime date
... author S 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) Who and/or what authored the composition
... title S 1..1 string Document Title
... confidentiality 0..0
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:legal_attester S 0..1 BackboneElement attester
..... mode S 1..1 code mode
Fixed Value: legal
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:professional_attester S 0..* BackboneElement attester
..... mode S 1..1 code mode
Fixed Value: professional
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:personal_attester S 0..* BackboneElement attester
..... mode S 1..1 code mode
Fixed Value: personal
..... party S 1..1 Reference(US Core Patient Profile | RelatedPerson) party
... custodian S 1..1 Reference(US Core Organization Profile) custodian

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Clinical Document This is an abstract profile. Child profiles: CarePlan, ConsultationNote, ContinuityOfCareDocument, DiagnosticImagingReport, DischargeSummary, HistoryAndPhysical, OperativeNote, ProcedureNote, ProgressNote, ReferralNote, TransferSummary
A set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:versionNumber 0..* string Version-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:version_number_extension S 0..1 integer Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
.... extension:data_enterer_extension S 0..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
.... extension:informant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
.... extension:information_recipient_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
.... extension:participant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
.... extension:performer_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
.... extension:authorization_extension S 0..* Reference(Consent) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
.... extension:order_extension S 0..* Reference(ServiceRequest) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier identifier
... status ?!Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type SΣ 1..1 CodeableConcept Kind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 0..1 Reference(US Core Patient Profile | Group) Who and/or what the composition is about
... encounter SΣ 0..1 Reference(US Core Encounter Profile) Context of the Composition
... date SΣ 1..1 dateTime date
... author SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) Who and/or what authored the composition
... title SΣ 1..1 string Document Title
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... 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 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
..... time 0..1 dateTime When the composition was attested
..... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
.... attester:legal_attester S 0..1 BackboneElement attester
..... 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 mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: legal
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:professional_attester S 0..* BackboneElement attester
..... 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 mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: professional
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:personal_attester S 0..* BackboneElement attester
..... 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 mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: personal
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(US Core Patient Profile | RelatedPerson) party
... custodian SΣ 1..1 Reference(US Core Organization Profile) custodian
... relatesTo 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 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(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 C 0..* BackboneElement Composition is broken into sections
Constraints: cmp-1, cmp-2
.... 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 0..1 string Label for section (e.g. for ToC)
.... code 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 C 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
.... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
.... entry C 0..* Reference(Resource) A reference to data that supports this section
.... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section C 0..* See section (Composition) Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
From the FHIR Standard
Composition.typepreferredFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
From the FHIR Standard
Composition.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
From the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:legal_attester.moderequiredFixed Value: legal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:professional_attester.moderequiredFixed Value: professional
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:personal_attester.moderequiredFixed Value: personal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
From the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Clinical Document This is an abstract profile. Child profiles: CarePlan, ConsultationNote, ContinuityOfCareDocument, DiagnosticImagingReport, DischargeSummary, HistoryAndPhysical, OperativeNote, ProcedureNote, ProgressNote, ReferralNote, TransferSummary
A set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language S 1..1 code language
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... Slices for extension Content/Rules for all slices
.... extension:versionNumber 0..* string Version-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:version_number_extension S 0..1 integer Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
.... extension:data_enterer_extension S 0..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
.... extension:informant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
.... extension:information_recipient_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
.... extension:participant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
.... extension:performer_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
.... extension:authorization_extension S 0..* Reference(Consent) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
.... extension:order_extension S 0..* Reference(ServiceRequest) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... identifier SΣ 1..1 Identifier identifier
... status ?!Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type SΣ 1..1 CodeableConcept Kind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
... subject SΣ 0..1 Reference(US Core Patient Profile | Group) Who and/or what the composition is about
... encounter SΣ 0..1 Reference(US Core Encounter Profile) Context of the Composition
... date SΣ 1..1 dateTime date
... author SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) Who and/or what authored the composition
... title SΣ 1..1 string Document Title
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... attester:legal_attester S 0..1 BackboneElement attester
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: legal
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:professional_attester S 0..* BackboneElement attester
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: professional
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:personal_attester S 0..* BackboneElement attester
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: personal
..... party S 1..1 Reference(US Core Patient Profile | RelatedPerson) party
... custodian SΣ 1..1 Reference(US Core Organization Profile) custodian

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
From the FHIR Standard
Composition.typepreferredFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
From the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:legal_attester.moderequiredFixed Value: legal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:professional_attester.moderequiredFixed Value: professional
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:personal_attester.moderequiredFixed Value: personal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from Clinical Document

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Clinical Document This is an abstract profile. Child profiles: CarePlan, ConsultationNote, ContinuityOfCareDocument, DiagnosticImagingReport, DischargeSummary, HistoryAndPhysical, OperativeNote, ProcedureNote, ProgressNote, ReferralNote, TransferSummary
A set of resources composed into a single coherent clinical statement with clinical attestation
... language S 1..1 code language
... Slices for extension Content/Rules for all slices
.... extension:version_number_extension S 0..1 integer Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
.... extension:data_enterer_extension S 0..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
.... extension:informant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
.... extension:information_recipient_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
.... extension:participant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
.... extension:performer_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
.... extension:authorization_extension S 0..* Reference(Consent) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
.... extension:order_extension S 0..* Reference(ServiceRequest) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... identifier S 1..1 Identifier identifier
... subject S 0..1 Reference(US Core Patient Profile | Group) Who and/or what the composition is about
... encounter S 0..1 Reference(US Core Encounter Profile) Context of the Composition
... date S 1..1 dateTime date
... author S 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) Who and/or what authored the composition
... title S 1..1 string Document Title
... confidentiality 0..0
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:legal_attester S 0..1 BackboneElement attester
..... mode S 1..1 code mode
Fixed Value: legal
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:professional_attester S 0..* BackboneElement attester
..... mode S 1..1 code mode
Fixed Value: professional
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:personal_attester S 0..* BackboneElement attester
..... mode S 1..1 code mode
Fixed Value: personal
..... party S 1..1 Reference(US Core Patient Profile | RelatedPerson) party
... custodian S 1..1 Reference(US Core Organization Profile) custodian

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Clinical Document This is an abstract profile. Child profiles: CarePlan, ConsultationNote, ContinuityOfCareDocument, DiagnosticImagingReport, DischargeSummary, HistoryAndPhysical, OperativeNote, ProcedureNote, ProgressNote, ReferralNote, TransferSummary
A set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:versionNumber 0..* string Version-specific identifier for composition
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:version_number_extension S 0..1 integer Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/VersionNumber
.... extension:data_enterer_extension S 0..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Extension
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/DataEntererExtension
.... extension:informant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) informant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformantExtension
.... extension:information_recipient_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile) informationRecipient
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/InformationRecipientExtension
.... extension:participant_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Patient Profile | RelatedPerson) participant
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/ParticipantExtension
.... extension:performer_extension S 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) performer
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/PerformerExtension
.... extension:authorization_extension S 0..* Reference(Consent) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/AuthorizationExtension
.... extension:order_extension S 0..* Reference(ServiceRequest) authorization
URL: http://hl7.org/fhir/us/ccda/StructureDefinition/OrderExtension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier identifier
... status ?!Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type SΣ 1..1 CodeableConcept Kind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 0..1 Reference(US Core Patient Profile | Group) Who and/or what the composition is about
... encounter SΣ 0..1 Reference(US Core Encounter Profile) Context of the Composition
... date SΣ 1..1 dateTime date
... author SΣ 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) Who and/or what authored the composition
... title SΣ 1..1 string Document Title
... Slices for attester 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... 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 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
..... time 0..1 dateTime When the composition was attested
..... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
.... attester:legal_attester S 0..1 BackboneElement attester
..... 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 mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: legal
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:professional_attester S 0..* BackboneElement attester
..... 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 mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: professional
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) party
.... attester:personal_attester S 0..* BackboneElement attester
..... 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 mode
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: personal
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(US Core Patient Profile | RelatedPerson) party
... custodian SΣ 1..1 Reference(US Core Organization Profile) custodian
... relatesTo 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 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(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 C 0..* BackboneElement Composition is broken into sections
Constraints: cmp-1, cmp-2
.... 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 0..1 string Label for section (e.g. for ToC)
.... code 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 C 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
.... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
.... entry C 0..* Reference(Resource) A reference to data that supports this section
.... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section C 0..* See section (Composition) Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Composition.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
From the FHIR Standard
Composition.typepreferredFHIRDocumentTypeCodes
http://hl7.org/fhir/ValueSet/doc-typecodes
From the FHIR Standard
Composition.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
From the FHIR Standard
Composition.attester.moderequiredCompositionAttestationMode
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:legal_attester.moderequiredFixed Value: legal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:professional_attester.moderequiredFixed Value: professional
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.attester:personal_attester.moderequiredFixed Value: personal
http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
From the FHIR Standard
Composition.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
From the FHIR Standard
Composition.event.codeexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.codeexampleDocumentSectionCodes
http://hl7.org/fhir/ValueSet/doc-section-codes
From the FHIR Standard
Composition.section.moderequiredListMode
http://hl7.org/fhir/ValueSet/list-mode|4.0.1
From the FHIR Standard
Composition.section.orderedBypreferredListOrderCodes
http://hl7.org/fhir/ValueSet/list-order
From the FHIR Standard
Composition.section.emptyReasonpreferredListEmptyReasons
http://hl7.org/fhir/ValueSet/list-empty-reason
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron