FHIR Clinical Documents
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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

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Behavior: Operation Definitions

These are custom operations that can be supported by and/or invoked by systems conforming to this implementation guide.

Convert to transaction bundle

Convert a FHIR Clinical Document into a FHIR transaction bundle.

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide.

FHIR Clinical Document Bundle Profile

Universal starting point for specifying a FHIR Clinical Document.

FHIR Clinical Document Composition Profile

Starting point for a specification for a composition of a FHIR Clinical Document.

Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide.

Consent Extension

Consent Extension refers to a FHIR Consent instance that indicates a patient's consent

Data Enterer Extension

The Data Enterer Extension 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.

Informant Extension

Informant Extension describes 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.

Information Recipient Extension

The Information Recipient Extension records the intended recipient of the information at the time the document was created.

Order Extension

The Order Extension represents orders that are fulfilled by this document such as a radiologists report of an x-ray.

Participant Extension

Participant Extension identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide.

Clinical Document Participant Types Value set

Subset of codes from v3-ParticipationType for use as Clinical Document Participant Type codes

Clinical Document Participant Types that are information recipients

Subset of codes from v3-ParticipationType for use as Clinical Document Participant Type codes, which are specifically CDA information recipients

Clinical Document Participant Value set

Value set is a subset that limits to values not used in other slices

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.

124a6916-5d84-4b8c-b250-10cefb8e6e86

Example composition content

47600e0f-b6b5-4308-84b5-5dec157f7637

Example composition content

541a72a8-df75-4484-ac89-ac4923f03b81

Example composition content

673f8db5-0ffd-4395-9657-6da00420bbc1

Example composition content

Discharge Summary

Composition example for FHIR Clinical Document

Discharge Summary Revision

Composition revision example for FHIR Clinical Document

clinical-document-as-transaction-bundle

Document Bundle example for FHIR Clinical Document

clinical-document-bundle-example1

Document Bundle example for FHIR Clinical Document

clinical-document-bundle-revision

Document Bundle revision example for FHIR Clinical Document

consent1

Example composition content

custodianOrganization

Example composition content

d1

Example composition content

doc-example

Example composition content

example

Example composition content

example2

Example composition content

revised-124a6916-5d84-4b8c-b250-10cefb8e6e86

Example composition content

revised-47600e0f-b6b5-4308-84b5-5dec157f7637

Example composition content

revised-541a72a8-df75-4484-ac89-ac4923f03b81

Example composition content

revised-673f8db5-0ffd-4395-9657-6da00420bbc1

Example composition content

revised-consent1

Example composition content

revised-custodianOrganization

Example composition content

revised-d1

Example composition content

revised-doc-example

Example composition content

revised-example

Example composition content

revised-example2

Example composition content

revised-service1

Example composition content

service1

Example composition content