Guía de Implementación cl core FHIR R4, (Versión Evolutiva), published by HL7 Chile. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7Chile/clcore_ig/ and changes regularly. See the Directory of published versions

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Resource Profile: CL Documento

De un formato genérico para documento clínico en Chile.

Usages:

• Examples for this Profile: Composition/DocumentoEjemplo1
• CapabilityStatements using this Profile: CapabilityStatement Cliente Cl Core and CapabilityStatement Servidor Cl Core

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..1	Identifier	Identificador local para recurso de documento que puede ser distinto para cada versión del mismo
status	?!SΣ	1..1	code	Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar
type	SΣ	1..1	CodeableConcept	Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (preferred)
subject	SΣ	0..1	Reference(Resource)	Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno.
encounter	SΣ	0..1	Reference(CL Encuentro Clínico)	Contexto asistencial en el cual se generó Documento.
date	SΣ	1..1	dateTime	Fecha en la cual se editó el documento
author	SΣ	1..*	Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización)	Quien Ha creado el documento
title	SΣ	1..1	string	Título del documento generado
attester	S	0..*	BackboneElement	Profesionales validadores del documento
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode	S	1..1	code	Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR
time	S	0..1	dateTime	Fecha y Hora de la validación
party	S	0..1	Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización)	Quien validó
custodian	SΣ	0..1	Reference(CL Organización)	Organización que mantiene los documentos
section	SC	1..*	BackboneElement	Sección del documento Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	0..1	CodeableConcept	Código que define el tipo de sección Binding: DocumentSectionCodes (example)
text	SC	0..1	Narrative	Texto que describe el contenido de la sección This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	SC	0..*	Reference(Resource)	Recurso referenciado en esta sección
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status From the FHIR Standard
Composition.type	preferred	VSTiposDocClinico(a valid code from LOINC) https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico From this IG
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode From the FHIR Standard
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
identifier	S	0..1	Identifier	Identificador local para recurso de documento que puede ser distinto para cada versión del mismo
status	S	1..1	code	Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar
type	S	1..1	CodeableConcept	Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (preferred)
subject	S	0..1	Reference(Resource)	Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno.
encounter	S	0..1	Reference(CL Encuentro Clínico)	Contexto asistencial en el cual se generó Documento.
date	S	1..1	dateTime	Fecha en la cual se editó el documento
author	S	1..*	Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización)	Quien Ha creado el documento
title	S	1..1	string	Título del documento generado
attester	S	0..*	BackboneElement	Profesionales validadores del documento
mode	S	1..1	code	Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR
time	S	0..1	dateTime	Fecha y Hora de la validación
party	S	0..1	Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización)	Quien validó
custodian	S	0..1	Reference(CL Organización)	Organización que mantiene los documentos
section	S	1..*	BackboneElement	Sección del documento
code	S	0..1	CodeableConcept	Código que define el tipo de sección Binding: DocumentSectionCodes (example)
text	S	0..1	Narrative	Texto que describe el contenido de la sección
entry	S	0..*	Reference(Resource)	Recurso referenciado en esta sección
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status From the FHIR Standard
Composition.type	preferred	VSTiposDocClinico(a valid code from LOINC) https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico From this IG
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode From the FHIR Standard
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..1	Identifier	Identificador local para recurso de documento que puede ser distinto para cada versión del mismo
status	?!SΣ	1..1	code	Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar
type	SΣ	1..1	CodeableConcept	Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (preferred)
category	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	0..1	Reference(Resource)	Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno.
encounter	SΣ	0..1	Reference(CL Encuentro Clínico)	Contexto asistencial en el cual se generó Documento.
date	SΣ	1..1	dateTime	Fecha en la cual se editó el documento
author	SΣ	1..*	Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización)	Quien Ha creado el documento
title	SΣ	1..1	string	Título del documento generado
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.
attester	S	0..*	BackboneElement	Profesionales validadores del documento
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	Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR
time	S	0..1	dateTime	Fecha y Hora de la validación
party	S	0..1	Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización)	Quien validó
custodian	SΣ	0..1	Reference(CL Organización)	Organización que mantiene los documentos
relatesTo		0..*	BackboneElement	Relationships to other compositions/documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]		1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(Composition)
event	Σ	0..*	BackboneElement	The clinical service(s) being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
section	SC	1..*	BackboneElement	Sección del documento Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code	S	0..1	CodeableConcept	Código que define el tipo de sección Binding: DocumentSectionCodes (example)
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	Texto que describe el contenido de la sección This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	0..*	Reference(Resource)	Recurso referenciado en esta sección
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

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status From the FHIR Standard
Composition.type	preferred	VSTiposDocClinico(a valid code from LOINC) https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico From this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 From the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode From the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From the FHIR Standard
Composition.event.code	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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: 1 element
Must-Support: 17 elements

Structures

This structure refers to these other structures:

• CL Encuentro Clínico (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/EncounterCL)
• CL Prestador (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CorePrestadorCl)
• CL RolClinico (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CoreRolClinicoCl)
• CL Paciente (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CorePacienteCl)
• CL Organización (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CoreOrganizacionCl)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..1	Identifier	Identificador local para recurso de documento que puede ser distinto para cada versión del mismo
status	?!SΣ	1..1	code	Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar
type	SΣ	1..1	CodeableConcept	Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (preferred)
subject	SΣ	0..1	Reference(Resource)	Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno.
encounter	SΣ	0..1	Reference(CL Encuentro Clínico)	Contexto asistencial en el cual se generó Documento.
date	SΣ	1..1	dateTime	Fecha en la cual se editó el documento
author	SΣ	1..*	Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización)	Quien Ha creado el documento
title	SΣ	1..1	string	Título del documento generado
attester	S	0..*	BackboneElement	Profesionales validadores del documento
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode	S	1..1	code	Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR
time	S	0..1	dateTime	Fecha y Hora de la validación
party	S	0..1	Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización)	Quien validó
custodian	SΣ	0..1	Reference(CL Organización)	Organización que mantiene los documentos
section	SC	1..*	BackboneElement	Sección del documento Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	0..1	CodeableConcept	Código que define el tipo de sección Binding: DocumentSectionCodes (example)
text	SC	0..1	Narrative	Texto que describe el contenido de la sección This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	SC	0..*	Reference(Resource)	Recurso referenciado en esta sección
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status From the FHIR Standard
Composition.type	preferred	VSTiposDocClinico(a valid code from LOINC) https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico From this IG
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode From the FHIR Standard
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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()

Differential View

This structure is derived from Composition

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
identifier	S	0..1	Identifier	Identificador local para recurso de documento que puede ser distinto para cada versión del mismo
status	S	1..1	code	Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar
type	S	1..1	CodeableConcept	Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (preferred)
subject	S	0..1	Reference(Resource)	Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno.
encounter	S	0..1	Reference(CL Encuentro Clínico)	Contexto asistencial en el cual se generó Documento.
date	S	1..1	dateTime	Fecha en la cual se editó el documento
author	S	1..*	Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización)	Quien Ha creado el documento
title	S	1..1	string	Título del documento generado
attester	S	0..*	BackboneElement	Profesionales validadores del documento
mode	S	1..1	code	Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR
time	S	0..1	dateTime	Fecha y Hora de la validación
party	S	0..1	Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización)	Quien validó
custodian	S	0..1	Reference(CL Organización)	Organización que mantiene los documentos
section	S	1..*	BackboneElement	Sección del documento
code	S	0..1	CodeableConcept	Código que define el tipo de sección Binding: DocumentSectionCodes (example)
text	S	0..1	Narrative	Texto que describe el contenido de la sección
entry	S	0..*	Reference(Resource)	Recurso referenciado en esta sección
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status From the FHIR Standard
Composition.type	preferred	VSTiposDocClinico(a valid code from LOINC) https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico From this IG
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode From the FHIR Standard
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..1	Identifier	Identificador local para recurso de documento que puede ser distinto para cada versión del mismo
status	?!SΣ	1..1	code	Estado, valores posibles: preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Códigos requeridos por estándar
type	SΣ	1..1	CodeableConcept	Tipo de Documento según especificación de LOINC (Ej para Summarie IPS Loinc = #60591-5 Binding: Tipos de Documentos Clínicos (preferred)
category	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	0..1	Reference(Resource)	Recurso sobre el cual se ha generado este documento. Es deseable que el recurso cumpla con un perfil chileno.
encounter	SΣ	0..1	Reference(CL Encuentro Clínico)	Contexto asistencial en el cual se generó Documento.
date	SΣ	1..1	dateTime	Fecha en la cual se editó el documento
author	SΣ	1..*	Reference(CL Prestador | CL RolClinico | Device | CL Paciente | CL Organización)	Quien Ha creado el documento
title	SΣ	1..1	string	Título del documento generado
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.
attester	S	0..*	BackboneElement	Profesionales validadores del documento
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	Labor del Validador personal|profesional|legal|official Binding: CompositionAttestationMode (required): Códigos requeridos por FHIR
time	S	0..1	dateTime	Fecha y Hora de la validación
party	S	0..1	Reference(CL Paciente | RelatedPerson | CL Prestador | CL RolClinico | CL Organización)	Quien validó
custodian	SΣ	0..1	Reference(CL Organización)	Organización que mantiene los documentos
relatesTo		0..*	BackboneElement	Relationships to other compositions/documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]		1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(Composition)
event	Σ	0..*	BackboneElement	The clinical service(s) being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
section	SC	1..*	BackboneElement	Sección del documento Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code	S	0..1	CodeableConcept	Código que define el tipo de sección Binding: DocumentSectionCodes (example)
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	Texto que describe el contenido de la sección This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	0..*	Reference(Resource)	Recurso referenciado en esta sección
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

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status From the FHIR Standard
Composition.type	preferred	VSTiposDocClinico(a valid code from LOINC) https://hl7chile.cl/fhir/ig/clcore/ValueSet/VSTiposDocClinico From this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 From the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode From the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From the FHIR Standard
Composition.event.code	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes From the FHIR Standard
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 From the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order From the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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: 1 element
Must-Support: 17 elements

Structures

This structure refers to these other structures:

• CL Encuentro Clínico (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/EncounterCL)
• CL Prestador (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CorePrestadorCl)
• CL RolClinico (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CoreRolClinicoCl)
• CL Paciente (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CorePacienteCl)
• CL Organización (https://hl7chile.cl/fhir/ig/clcore/StructureDefinition/CoreOrganizacionCl)

Other representations of profile: CSV, Excel, Schematron