FHIR Clinical Documents
1.0.0-ballot - STU1 Ballot
FHIR Clinical Documents
1.0.0-ballot - STU1 Ballot
FHIR Clinical Documents, published by HL7 International / Structured Documents. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-clinical-document/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/clinical-document-composition | Version: 1.0.0-ballot | |||
| Draft as of 2024-12-18 | Maturity Level: 2 | Computable Name: ClinicalDocumentComposition | ||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
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Starting point for a specification for a composition of a FHIR Clinical Document.
A FHIR Clinical Document is a FHIR bundle of type=document where the first entry is a composition conforming to this profile.
Be aware of the modifier extension R5-Composition-status it is a backport of the R5 Composition.status to allow for additional status codes. Be cautious when using with the R4 Composition.status, which is required. The values could unintentionally cause confusion if they contradict each-other. The value sets do overlap, as well. The intent is to preadopt values found in R5 for status. In R6, the FHIR Clinical Document Composition Profile will only have one status field.
As noted in the introduction section on human readability:
To ensure the unambiguous communication of a clinical document's attested narrative, this IG requires that:
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition |
C | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation clindoc-limit-participantType: FHIR Clinical Document Composition Profile contains fields for AUT, AUTHEN, CST, LA, RCT, SBJ. These types are not allowed as types in the Participant Extension |
  language |
S | 0..1 | code | Language of the resource content |
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
   R5-Composition-version |
S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version |
| data-enterer |
S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension |
| informant |
S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension |
| information-recipient |
S | 0..* | (Complex) | An Information Recipient is the intended recipient of the information at the time the document was created. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension |
 participant |
S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension |
   Slices for extension |
Content/Rules for all slices | |||
  extension:type |
1..* | Extension | Extension | |
 value[x] |
1..1 | CodeableConcept | Value of extension Binding: Clinical Document Participant Value set (required): particpants that are not a data-enter, information-recipient nor an informant | |
| consent |
S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension |
 order |
S | 0..* | Reference(ServiceRequest) | order URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/OrderExtension |
 Slices for modifierExtension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| modifierExtension:R5-Composition-status |
S | 0..1 | R5 Composition.status | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. |
| identifier |
S | 0..1 | Identifier | Version-independent identifier for the Composition |
| type |
S | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) |
 subject |
S | 1..1 | Reference(Patient | Group) | Who and/or what the composition is about |
| date |
S | 1..1 | dateTime | Composition editing time |
| author |
S | 1..* | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Device | Organization) | Who and/or what authored the composition |
| title |
S | 1..1 | string | Human Readable name/title |
| Slices for attester |
S | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode |
| attester:All Slices |
Content/Rules for all slices | |||
| mode |
S | 1..1 | code | personal | professional | legal | official |
| time |
S | 0..1 | dateTime | When the composition was attested |
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
| attester:legal_attester |
S | 0..1 | BackboneElement | aka legal authenticator |
| mode |
1..1 | code | personal | professional | legal | official Required Pattern: legal | |
| attester:professional_attester |
S | 0..* | BackboneElement | aka authenticator |
| mode |
1..1 | code | personal | professional | legal | official Required Pattern: professional | |
| custodian |
S | 1..1 | Reference(Organization) | Organization which maintains the composition |
| Slices for relatesTo |
S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code |
| relatesTo:All Slices |
Content/Rules for all slices | |||
| Slices for target[x] |
1..1 | Identifier, Reference(Composition) | Target of the relationship Slice: Unordered, Open by type:$this | |
| target[x]:targetIdentifier |
0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document | |
 system |
1..1 | uri | The namespace for the identifier value | |
| value |
1..1 | string | The value that is unique | |
| relatesTo:replaced_document |
S | 0..* | BackboneElement | The document(s) being superceded |
| code |
1..1 | code | replaces | transforms | signs | appends Required Pattern: replaces | |
| Slices for target[x] |
Content/Rules for all slices | |||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship | |
| relatesTo:appended_document |
S | 0..* | BackboneElement | The document(s) being appended too |
| code |
1..1 | code | replaces | transforms | signs | appends Required Pattern: appends | |
| Slices for target[x] |
Content/Rules for all slices | |||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship | |
 section |
S | 1..* | BackboneElement | Composition is broken into sections |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
S | 0..1 | CodeableConcept | Classification of section (recommended) |
 text |
S | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.extension:participant.extension:type.value[x] | required | ClinicalDocParticipantVshttp://hl7.org/fhir/uv/fhir-clinical-document/ValueSet/clinical-doc-participant-vsfrom this IG |
| Id | Grade | Path(s) | Details | Requirements |
| clindoc-limit-participantType | error | Composition | FHIR Clinical Document Composition Profile contains fields for AUT, AUTHEN, CST, LA, RCT, SBJ. These types are not allowed as types in the Participant Extension : extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='AUT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='AUTHEN').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='CST').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='LA').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='RCT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='SBJ').not() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
C | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management clindoc-limit-participantType: FHIR Clinical Document Composition Profile contains fields for AUT, AUTHEN, CST, LA, RCT, SBJ. These types are not allowed as types in the Participant Extension | ||||
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children | ||||
| language |
S | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
ele-1: All FHIR elements must have a @value or children | ||||
 text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation ele-1: All FHIR elements must have a @value or children | ||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
| R5-Composition-version |
S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| data-enterer |
S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| informant |
S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| information-recipient |
S | 0..* | (Complex) | An Information Recipient is the intended recipient of the information at the time the document was created. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| participant |
S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
 Slices for extension |
2..* | Extension | Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
 extension:type |
1..* | Extension | Extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "type" | |||||
| value[x] |
1..1 | CodeableConcept | Value of extension Binding: Clinical Document Participant Value set (required): particpants that are not a data-enter, information-recipient nor an informant ele-1: All FHIR elements must have a @value or children | |||||
| extension:function |
0..* | Extension | Exact function of the participant in the creation of the clinical document. This is more granular than type. ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "function" | |||||
| value[x] |
1..1 | CodeableConcept | Value of extension Binding: ParticipationFunction (extensible) ele-1: All FHIR elements must have a @value or children | |||||
| extension:time |
0..1 | Extension | Time period of participation ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "time" | |||||
| value[x] |
1..1 | Period | Value of extension ele-1: All FHIR elements must have a @value or children | |||||
| extension:party |
S | 1..1 | Extension | participant ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "party" | |||||
| value[x] |
1..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Organization) | Value of extension ele-1: All FHIR elements must have a @value or children | |||||
| url |
1..1 | uri | "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension" | |||||
| consent |
S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| order |
S | 0..* | Reference(ServiceRequest) | order URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/OrderExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| Slices for modifierExtension |
?! | 0..* | Extension | Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| modifierExtension:R5-Composition-status |
?!S | 0..1 | R5 Composition.status | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| identifier |
SΣ | 0..1 | Identifier | Version-independent identifier for the Composition ele-1: All FHIR elements must have a @value or children | ||||
| status |
?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. ele-1: All FHIR elements must have a @value or children | ||||
| subject |
SΣ | 1..1 | Reference(Patient | Group) | Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children | ||||
| date |
SΣ | 1..1 | dateTime | Composition editing time ele-1: All FHIR elements must have a @value or children | ||||
| author |
SΣ | 1..* | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Device | Organization) | Who and/or what authored the composition ele-1: All FHIR elements must have a @value or children | ||||
| title |
SΣ | 1..1 | string | Human Readable name/title ele-1: All FHIR elements must have a @value or children | ||||
| Slices for attester |
S | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode ele-1: All FHIR elements must have a @value or children | ||||
| attester:All Slices |
Content/Rules for all slices | |||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children | ||||
| time |
S | 0..1 | dateTime | When the composition was attested ele-1: All FHIR elements must have a @value or children | ||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition ele-1: All FHIR elements must have a @value or children | ||||
| attester:legal_attester |
S | 0..1 | BackboneElement | aka legal authenticator ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Required Pattern: legal | |||||
| attester:professional_attester |
S | 0..* | BackboneElement | aka authenticator ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Required Pattern: professional | |||||
| custodian |
SΣ | 1..1 | Reference(Organization) | Organization which maintains the composition ele-1: All FHIR elements must have a @value or children | ||||
| Slices for relatesTo |
S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code ele-1: All FHIR elements must have a @value or children | ||||
| relatesTo:All Slices |
Content/Rules for all slices | |||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. ele-1: All FHIR elements must have a @value or children | |||||
| Slices for target[x] |
1..1 | Target of the relationship Slice: Unordered, Open by type:$this ele-1: All FHIR elements must have a @value or children | ||||||
| targetIdentifier |
Identifier | |||||||
| targetReference |
Reference(Composition) | |||||||
| target[x]:targetIdentifier |
0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document ele-1: All FHIR elements must have a @value or children | |||||
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children | ||||
| system |
Σ | 1..1 | uri | The namespace for the identifier value ele-1: All FHIR elements must have a @value or children Example General: http://www.acme.com/identifiers/patient | ||||
| value |
Σ | 1..1 | string | The value that is unique ele-1: All FHIR elements must have a @value or children Example General: 123456 | ||||
| relatesTo:replaced_document |
S | 0..* | BackboneElement | The document(s) being superceded ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. ele-1: All FHIR elements must have a @value or children Required Pattern: replaces | |||||
| Slices for target[x] |
Content/Rules for all slices | |||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship ele-1: All FHIR elements must have a @value or children | |||||
| relatesTo:appended_document |
S | 0..* | BackboneElement | The document(s) being appended too ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. ele-1: All FHIR elements must have a @value or children Required Pattern: appends | |||||
| Slices for target[x] |
Content/Rules for all slices | |||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship ele-1: All FHIR elements must have a @value or children | |||||
| section |
SC | 1..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children | ||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Composition.extension:participant.extension:type.value[x] | required | ClinicalDocParticipantVshttp://hl7.org/fhir/uv/fhir-clinical-document/ValueSet/clinical-doc-participant-vsfrom this IG | ||||
| Composition.extension:participant.extension:function.value[x] | extensible | ParticipationFunctionhttp://terminology.hl7.org/ValueSet/v3-ParticipationFunction | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legal_attester.mode | required | Pattern: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:professional_attester.mode | required | Pattern: professionalhttp://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.relatesTo.target[x]:targetIdentifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo:replaced_document.code | required | Pattern: replaceshttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo:appended_document.code | required | Pattern: appendshttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| clindoc-limit-participantType | error | Composition | FHIR Clinical Document Composition Profile contains fields for AUT, AUTHEN, CST, LA, RCT, SBJ. These types are not allowed as types in the Participant Extension : extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='AUT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='AUTHEN').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='CST').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='LA').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='RCT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='SBJ').not() | |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : 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-4 | error | Composition | If 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-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
C | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation clindoc-limit-participantType: FHIR Clinical Document Composition Profile contains fields for AUT, AUTHEN, CST, LA, RCT, SBJ. These types are not allowed as types in the Participant Extension | ||||
| 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 |
S | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| ||||
| text |
S | 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 | |||||
| R5-Composition-version |
S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version | ||||
| data-enterer |
S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension | ||||
| informant |
S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension | ||||
| information-recipient |
S | 0..* | (Complex) | An Information Recipient is the intended recipient of the information at the time the document was created. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension | ||||
| participant |
S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
2..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| extension:type |
1..* | Extension | Extension | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "type" | |||||
| value[x] |
1..1 | CodeableConcept | Value of extension Binding: Clinical Document Participant Value set (required): particpants that are not a data-enter, information-recipient nor an informant | |||||
| extension:function |
0..* | Extension | Exact function of the participant in the creation of the clinical document. This is more granular than type. | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "function" | |||||
| value[x] |
1..1 | CodeableConcept | Value of extension Binding: ParticipationFunction (extensible) | |||||
| extension:time |
0..1 | Extension | Time period of participation | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "time" | |||||
| value[x] |
1..1 | Period | Value of extension | |||||
| extension:party |
S | 1..1 | Extension | participant | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "party" | |||||
| value[x] |
1..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Organization) | Value of extension | |||||
| url |
1..1 | uri | "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension" | |||||
| consent |
S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension | ||||
| order |
S | 0..* | Reference(ServiceRequest) | order URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/OrderExtension | ||||
| Slices for modifierExtension |
?! | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| modifierExtension:R5-Composition-status |
?!S | 0..1 | R5 Composition.status | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. | ||||
| identifier |
SΣ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| 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 | 1..1 | Reference(Patient | Group) | Who and/or what the composition is about | ||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
| date |
SΣ | 1..1 | dateTime | Composition editing time | ||||
| author |
SΣ | 1..* | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Device | Organization) | Who and/or what authored the composition | ||||
| title |
SΣ | 1..1 | string | Human Readable name/title | ||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| Slices for attester |
S | 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 |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | ||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||
| attester:legal_attester |
S | 0..1 | BackboneElement | aka legal authenticator | ||||
| 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. Required Pattern: legal | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| attester:professional_attester |
S | 0..* | BackboneElement | aka authenticator | ||||
| 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. Required Pattern: professional | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian |
SΣ | 1..1 | Reference(Organization) | Organization which maintains the composition | ||||
| Slices for relatesTo |
S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code | ||||
| relatesTo: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 | ||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| Slices for target[x] |
1..1 | Target of the relationship Slice: Unordered, Open by type:$this | ||||||
| targetIdentifier |
Identifier | |||||||
| targetReference |
Reference(Composition) | |||||||
| target[x]:targetIdentifier |
0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type |
Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
| system |
Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value |
Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
| period |
Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner |
Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| relatesTo:replaced_document |
S | 0..* | BackboneElement | The document(s) being superceded | ||||
| 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. Required Pattern: replaces | |||||
| Slices for target[x] |
Content/Rules for all slices | |||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship | |||||
| relatesTo:appended_document |
S | 0..* | BackboneElement | The document(s) being appended too | ||||
| 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. Required Pattern: appends | |||||
| Slices for target[x] |
Content/Rules for all slices | |||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship | |||||
| event |
Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period |
Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| section |
SC | 1..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code |
S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | ||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| 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 | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Composition.extension:participant.extension:type.value[x] | required | ClinicalDocParticipantVshttp://hl7.org/fhir/uv/fhir-clinical-document/ValueSet/clinical-doc-participant-vsfrom this IG | ||||
| Composition.extension:participant.extension:function.value[x] | extensible | ParticipationFunctionhttp://terminology.hl7.org/ValueSet/v3-ParticipationFunction | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26from the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legal_attester.mode | required | Pattern: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:professional_attester.mode | required | Pattern: professionalhttp://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.relatesTo.target[x]:targetIdentifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.target[x]:targetIdentifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | ||||
| Composition.relatesTo:replaced_document.code | required | Pattern: replaceshttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo:appended_document.code | required | Pattern: appendshttp://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 | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://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.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| clindoc-limit-participantType | error | Composition | FHIR Clinical Document Composition Profile contains fields for AUT, AUTHEN, CST, LA, RCT, SBJ. These types are not allowed as types in the Participant Extension : extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='AUT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='AUTHEN').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='CST').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='LA').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='RCT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='SBJ').not() | |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : 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-4 | error | Composition | If 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-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 4 elements(4 nested mandatory elements)
Must-Support: 30 elements
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 2
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
C | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation clindoc-limit-participantType: FHIR Clinical Document Composition Profile contains fields for AUT, AUTHEN, CST, LA, RCT, SBJ. These types are not allowed as types in the Participant Extension |
| language |
S | 0..1 | code | Language of the resource content |
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| R5-Composition-version |
S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version |
| data-enterer |
S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension |
| informant |
S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension |
| information-recipient |
S | 0..* | (Complex) | An Information Recipient is the intended recipient of the information at the time the document was created. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension |
| participant |
S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension |
| Slices for extension |
Content/Rules for all slices | |||
| extension:type |
1..* | Extension | Extension | |
| value[x] |
1..1 | CodeableConcept | Value of extension Binding: Clinical Document Participant Value set (required): particpants that are not a data-enter, information-recipient nor an informant | |
| consent |
S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension |
| order |
S | 0..* | Reference(ServiceRequest) | order URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/OrderExtension |
| Slices for modifierExtension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| modifierExtension:R5-Composition-status |
S | 0..1 | R5 Composition.status | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. |
| identifier |
S | 0..1 | Identifier | Version-independent identifier for the Composition |
| type |
S | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) |
| subject |
S | 1..1 | Reference(Patient | Group) | Who and/or what the composition is about |
| date |
S | 1..1 | dateTime | Composition editing time |
| author |
S | 1..* | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Device | Organization) | Who and/or what authored the composition |
| title |
S | 1..1 | string | Human Readable name/title |
| Slices for attester |
S | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode |
| attester:All Slices |
Content/Rules for all slices | |||
| mode |
S | 1..1 | code | personal | professional | legal | official |
| time |
S | 0..1 | dateTime | When the composition was attested |
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
| attester:legal_attester |
S | 0..1 | BackboneElement | aka legal authenticator |
| mode |
1..1 | code | personal | professional | legal | official Required Pattern: legal | |
| attester:professional_attester |
S | 0..* | BackboneElement | aka authenticator |
| mode |
1..1 | code | personal | professional | legal | official Required Pattern: professional | |
| custodian |
S | 1..1 | Reference(Organization) | Organization which maintains the composition |
| Slices for relatesTo |
S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code |
| relatesTo:All Slices |
Content/Rules for all slices | |||
| Slices for target[x] |
1..1 | Identifier, Reference(Composition) | Target of the relationship Slice: Unordered, Open by type:$this | |
| target[x]:targetIdentifier |
0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document | |
| system |
1..1 | uri | The namespace for the identifier value | |
| value |
1..1 | string | The value that is unique | |
| relatesTo:replaced_document |
S | 0..* | BackboneElement | The document(s) being superceded |
| code |
1..1 | code | replaces | transforms | signs | appends Required Pattern: replaces | |
| Slices for target[x] |
Content/Rules for all slices | |||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship | |
| relatesTo:appended_document |
S | 0..* | BackboneElement | The document(s) being appended too |
| code |
1..1 | code | replaces | transforms | signs | appends Required Pattern: appends | |
| Slices for target[x] |
Content/Rules for all slices | |||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship | |
| section |
S | 1..* | BackboneElement | Composition is broken into sections |
| title |
S | 1..1 | string | Label for section (e.g. for ToC) |
| code |
S | 0..1 | CodeableConcept | Classification of section (recommended) |
| text |
S | 0..1 | Narrative | Text summary of the section, for human interpretation |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.extension:participant.extension:type.value[x] | required | ClinicalDocParticipantVshttp://hl7.org/fhir/uv/fhir-clinical-document/ValueSet/clinical-doc-participant-vsfrom this IG |
| Id | Grade | Path(s) | Details | Requirements |
| clindoc-limit-participantType | error | Composition | FHIR Clinical Document Composition Profile contains fields for AUT, AUTHEN, CST, LA, RCT, SBJ. These types are not allowed as types in the Participant Extension : extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='AUT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='AUTHEN').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='CST').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='LA').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='RCT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='SBJ').not() |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
C | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management clindoc-limit-participantType: FHIR Clinical Document Composition Profile contains fields for AUT, AUTHEN, CST, LA, RCT, SBJ. These types are not allowed as types in the Participant Extension | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children | ||||
| language |
S | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
ele-1: All FHIR elements must have a @value or children | ||||
| text |
S | 0..1 | Narrative | Text summary of the resource, for human interpretation ele-1: All FHIR elements must have a @value or children | ||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
| R5-Composition-version |
S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| data-enterer |
S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| informant |
S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| information-recipient |
S | 0..* | (Complex) | An Information Recipient is the intended recipient of the information at the time the document was created. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| participant |
S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| Slices for extension |
2..* | Extension | Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
| extension:type |
1..* | Extension | Extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "type" | |||||
| value[x] |
1..1 | CodeableConcept | Value of extension Binding: Clinical Document Participant Value set (required): particpants that are not a data-enter, information-recipient nor an informant ele-1: All FHIR elements must have a @value or children | |||||
| extension:function |
0..* | Extension | Exact function of the participant in the creation of the clinical document. This is more granular than type. ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "function" | |||||
| value[x] |
1..1 | CodeableConcept | Value of extension Binding: ParticipationFunction (extensible) ele-1: All FHIR elements must have a @value or children | |||||
| extension:time |
0..1 | Extension | Time period of participation ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "time" | |||||
| value[x] |
1..1 | Period | Value of extension ele-1: All FHIR elements must have a @value or children | |||||
| extension:party |
S | 1..1 | Extension | participant ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "party" | |||||
| value[x] |
1..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Organization) | Value of extension ele-1: All FHIR elements must have a @value or children | |||||
| url |
1..1 | uri | "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension" | |||||
| consent |
S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| order |
S | 0..* | Reference(ServiceRequest) | order URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/OrderExtension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| Slices for modifierExtension |
?! | 0..* | Extension | Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| modifierExtension:R5-Composition-status |
?!S | 0..1 | R5 Composition.status | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| identifier |
SΣ | 0..1 | Identifier | Version-independent identifier for the Composition ele-1: All FHIR elements must have a @value or children | ||||
| status |
?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. ele-1: All FHIR elements must have a @value or children | ||||
| subject |
SΣ | 1..1 | Reference(Patient | Group) | Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children | ||||
| date |
SΣ | 1..1 | dateTime | Composition editing time ele-1: All FHIR elements must have a @value or children | ||||
| author |
SΣ | 1..* | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Device | Organization) | Who and/or what authored the composition ele-1: All FHIR elements must have a @value or children | ||||
| title |
SΣ | 1..1 | string | Human Readable name/title ele-1: All FHIR elements must have a @value or children | ||||
| Slices for attester |
S | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode ele-1: All FHIR elements must have a @value or children | ||||
| attester:All Slices |
Content/Rules for all slices | |||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children | ||||
| time |
S | 0..1 | dateTime | When the composition was attested ele-1: All FHIR elements must have a @value or children | ||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition ele-1: All FHIR elements must have a @value or children | ||||
| attester:legal_attester |
S | 0..1 | BackboneElement | aka legal authenticator ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Required Pattern: legal | |||||
| attester:professional_attester |
S | 0..* | BackboneElement | aka authenticator ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children Required Pattern: professional | |||||
| custodian |
SΣ | 1..1 | Reference(Organization) | Organization which maintains the composition ele-1: All FHIR elements must have a @value or children | ||||
| Slices for relatesTo |
S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code ele-1: All FHIR elements must have a @value or children | ||||
| relatesTo:All Slices |
Content/Rules for all slices | |||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. ele-1: All FHIR elements must have a @value or children | |||||
| Slices for target[x] |
1..1 | Target of the relationship Slice: Unordered, Open by type:$this ele-1: All FHIR elements must have a @value or children | ||||||
| targetIdentifier |
Identifier | |||||||
| targetReference |
Reference(Composition) | |||||||
| target[x]:targetIdentifier |
0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document ele-1: All FHIR elements must have a @value or children | |||||
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children | ||||
| system |
Σ | 1..1 | uri | The namespace for the identifier value ele-1: All FHIR elements must have a @value or children Example General: http://www.acme.com/identifiers/patient | ||||
| value |
Σ | 1..1 | string | The value that is unique ele-1: All FHIR elements must have a @value or children Example General: 123456 | ||||
| relatesTo:replaced_document |
S | 0..* | BackboneElement | The document(s) being superceded ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. ele-1: All FHIR elements must have a @value or children Required Pattern: replaces | |||||
| Slices for target[x] |
Content/Rules for all slices | |||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship ele-1: All FHIR elements must have a @value or children | |||||
| relatesTo:appended_document |
S | 0..* | BackboneElement | The document(s) being appended too ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. ele-1: All FHIR elements must have a @value or children Required Pattern: appends | |||||
| Slices for target[x] |
Content/Rules for all slices | |||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship ele-1: All FHIR elements must have a @value or children | |||||
| section |
SC | 1..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children | ||||
| code |
S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children | ||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation ele-1: All FHIR elements must have a @value or children | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Composition.extension:participant.extension:type.value[x] | required | ClinicalDocParticipantVshttp://hl7.org/fhir/uv/fhir-clinical-document/ValueSet/clinical-doc-participant-vsfrom this IG | ||||
| Composition.extension:participant.extension:function.value[x] | extensible | ParticipationFunctionhttp://terminology.hl7.org/ValueSet/v3-ParticipationFunction | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legal_attester.mode | required | Pattern: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:professional_attester.mode | required | Pattern: professionalhttp://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.relatesTo.target[x]:targetIdentifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo:replaced_document.code | required | Pattern: replaceshttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo:appended_document.code | required | Pattern: appendshttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| clindoc-limit-participantType | error | Composition | FHIR Clinical Document Composition Profile contains fields for AUT, AUTHEN, CST, LA, RCT, SBJ. These types are not allowed as types in the Participant Extension : extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='AUT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='AUTHEN').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='CST').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='LA').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='RCT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='SBJ').not() | |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : 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-4 | error | Composition | If 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-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
C | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation clindoc-limit-participantType: FHIR Clinical Document Composition Profile contains fields for AUT, AUTHEN, CST, LA, RCT, SBJ. These types are not allowed as types in the Participant Extension | ||||
| 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 |
S | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| ||||
| text |
S | 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 | |||||
| R5-Composition-version |
S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version | ||||
| data-enterer |
S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension | ||||
| informant |
S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension | ||||
| information-recipient |
S | 0..* | (Complex) | An Information Recipient is the intended recipient of the information at the time the document was created. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension | ||||
| participant |
S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
2..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| extension:type |
1..* | Extension | Extension | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "type" | |||||
| value[x] |
1..1 | CodeableConcept | Value of extension Binding: Clinical Document Participant Value set (required): particpants that are not a data-enter, information-recipient nor an informant | |||||
| extension:function |
0..* | Extension | Exact function of the participant in the creation of the clinical document. This is more granular than type. | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "function" | |||||
| value[x] |
1..1 | CodeableConcept | Value of extension Binding: ParticipationFunction (extensible) | |||||
| extension:time |
0..1 | Extension | Time period of participation | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "time" | |||||
| value[x] |
1..1 | Period | Value of extension | |||||
| extension:party |
S | 1..1 | Extension | participant | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | |||||||
| url |
1..1 | uri | "party" | |||||
| value[x] |
1..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device | Organization) | Value of extension | |||||
| url |
1..1 | uri | "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension" | |||||
| consent |
S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension | ||||
| order |
S | 0..* | Reference(ServiceRequest) | order URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/OrderExtension | ||||
| Slices for modifierExtension |
?! | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| modifierExtension:R5-Composition-status |
?!S | 0..1 | R5 Composition.status | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. | ||||
| identifier |
SΣ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| 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 | 1..1 | Reference(Patient | Group) | Who and/or what the composition is about | ||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
| date |
SΣ | 1..1 | dateTime | Composition editing time | ||||
| author |
SΣ | 1..* | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Device | Organization) | Who and/or what authored the composition | ||||
| title |
SΣ | 1..1 | string | Human Readable name/title | ||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| Slices for attester |
S | 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 |
S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | ||||
| time |
S | 0..1 | dateTime | When the composition was attested | ||||
| party |
S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | ||||
| attester:legal_attester |
S | 0..1 | BackboneElement | aka legal authenticator | ||||
| 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. Required Pattern: legal | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| attester:professional_attester |
S | 0..* | BackboneElement | aka authenticator | ||||
| 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. Required Pattern: professional | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian |
SΣ | 1..1 | Reference(Organization) | Organization which maintains the composition | ||||
| Slices for relatesTo |
S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code | ||||
| relatesTo: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 | ||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| Slices for target[x] |
1..1 | Target of the relationship Slice: Unordered, Open by type:$this | ||||||
| targetIdentifier |
Identifier | |||||||
| targetReference |
Reference(Composition) | |||||||
| target[x]:targetIdentifier |
0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type |
Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
| system |
Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value |
Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
| period |
Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner |
Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| relatesTo:replaced_document |
S | 0..* | BackboneElement | The document(s) being superceded | ||||
| 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. Required Pattern: replaces | |||||
| Slices for target[x] |
Content/Rules for all slices | |||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship | |||||
| relatesTo:appended_document |
S | 0..* | BackboneElement | The document(s) being appended too | ||||
| 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. Required Pattern: appends | |||||
| Slices for target[x] |
Content/Rules for all slices | |||||||
| target[x]:targetIdentifier |
1..1 | Identifier | Target of the relationship | |||||
| event |
Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period |
Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| section |
SC | 1..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title |
S | 1..1 | string | Label for section (e.g. for ToC) | ||||
| code |
S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | ||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
SC | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| 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 | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Composition.extension:participant.extension:type.value[x] | required | ClinicalDocParticipantVshttp://hl7.org/fhir/uv/fhir-clinical-document/ValueSet/clinical-doc-participant-vsfrom this IG | ||||
| Composition.extension:participant.extension:function.value[x] | extensible | ParticipationFunctionhttp://terminology.hl7.org/ValueSet/v3-ParticipationFunction | ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26from the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:legal_attester.mode | required | Pattern: legalhttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.attester:professional_attester.mode | required | Pattern: professionalhttp://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.relatesTo.target[x]:targetIdentifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.target[x]:targetIdentifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | ||||
| Composition.relatesTo:replaced_document.code | required | Pattern: replaceshttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo:appended_document.code | required | Pattern: appendshttp://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 | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://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.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| clindoc-limit-participantType | error | Composition | FHIR Clinical Document Composition Profile contains fields for AUT, AUTHEN, CST, LA, RCT, SBJ. These types are not allowed as types in the Participant Extension : extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='AUT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='AUTHEN').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='CST').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='LA').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='RCT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='SBJ').not() | |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : 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-4 | error | Composition | If 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-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 4 elements(4 nested mandatory elements)
Must-Support: 30 elements
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron
IG © 2024+ HL7 International / Structured Documents. Package hl7.fhir.uv.fhir-clinical-document#1.0.0-ballot based on FHIR 4.0.1. Generated 2024-12-18
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