Virtually Healthcare HL7 FHIR Implementation Guide
0.1.0-current - ci-build
Virtually Healthcare HL7 FHIR Implementation Guide, published by Virtually Healthcare. This guide is not an authorized publication; it is the continuous build for version 0.1.0-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Virtually-Healthcare/Virtually-Healthcare-FHIR-Implementation-Guide/ and changes regularly. See the Directory of published versions
Draft as of 2024-11-06 |
Definitions for the Composition resource profile.
Guidance on how to interpret the contents of this table can be found here
0. Composition |
Guidance on how to interpret the contents of this table can be found here
0. Composition | |
Definition | A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition SHALL be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition SHALL be included as subsequent entries in the Bundle, for example Patient, Practitioner, Encounter, etc. A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). |
Short | A set of resources composed into a single coherent clinical statement with clinical attestation |
Comments | While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical. |
Control | 0..* |
Is Modifier | false |
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-4: 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-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 (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-6: A resource should have narrative for robust management (text.`div`.exists()) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) |
2. Composition.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
Short | A set of rules under which this content was created |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
Control | 0..1 This element is affected by the following invariants: ele-1 |
Type | uri |
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
4. Composition.extension:careSettingType | |
Slice Name | careSettingType |
Definition | The type of care setting associated with a composition or a list. |
Short | The type of care setting associated with a composition or a list. |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..1 This element is affected by the following invariants: ele-1 |
Type | Extension(Extension UK Core Care Setting Type) (Extension Type: CodeableConcept) |
Standard Status | Normative (from Trial Use) |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() )ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
6. Composition.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* This element is affected by the following invariants: ele-1 |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them |
Standard Status | Normative (from Trial Use) |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() )ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
Slicing | This element introduces a set of slices on Composition.modifierExtension . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
8. Composition.status | |
Definition | The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. |
Short | preliminary | final | amended | entered-in-error |
Comments | If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. |
Control | 1..1 This element is affected by the following invariants: ele-1 |
Binding | The codes SHALL be taken from CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 (required to http://hl7.org/fhir/ValueSet/composition-status|4.0.1 )The workflow/clinical status of the composition. |
Type | code |
Is Modifier | true because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Requirements | Need to be able to mark interim, amended, or withdrawn compositions or documents. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
10. Composition.type | |
Definition | Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. |
Short | Kind of composition (SNOMED CT)Kind of composition (LOINC if possible) |
Comments | For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. |
Control | 1..1 This element is affected by the following invariants: ele-1 |
Binding | The codes SHOULD be taken from UK Core Document Typehttp://hl7.org/fhir/ValueSet/doc-typecodes (preferred to https://fhir.hl7.org.uk/ValueSet/UKCore-DocumentType )SNOMED CT Document Type Type of a composition. |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | Key metadata element describing the composition, used in searching/filtering. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
12. Composition.subject | |
Definition | Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). |
Short | Who and/or what the composition is about |
Comments | For clinical documents, this is usually the patient. |
Control | 0..1 This element is affected by the following invariants: ele-1 |
Type | Reference(Resource) |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ref-1: SHALL have a contained resource if a local reference is provided ( reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) ) |
14. Composition.date | |
Definition | The composition editing time, when the composition was last logically changed by the author. |
Short | Composition editing time |
Comments | The Last Modified Date on the composition may be after the date of the document was attested without being changed. |
Control | 1..1 This element is affected by the following invariants: ele-1 |
Type | dateTime |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Requirements | dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
16. Composition.author | |
Definition | Identifies who is responsible for the information in the composition, not necessarily who typed it in. |
Short | Who and/or what authored the composition |
Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. |
Control | 1..* This element is affected by the following invariants: ele-1 |
Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) |
Is Modifier | false |
Must Support | true |
Must Support Types | No must-support rules about the choice of types/profiles |
Summary | true |
Requirements | Identifies who is responsible for the content. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ref-1: SHALL have a contained resource if a local reference is provided ( reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) ) |
18. Composition.title | |
Definition | Official human-readable label for the composition. |
Short | Human Readable name/title |
Comments | For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period. |
Control | 1..1 This element is affected by the following invariants: ele-1 |
Type | string |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
20. Composition.confidentiality | |
Definition | The code specifying the level of confidentiality of the Composition. |
Short | As defined by affinity domain |
Comments | The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. |
Control | 0..1 This element is affected by the following invariants: ele-1 |
Binding | The codes SHALL be taken from v3.ConfidentialityClassification (2014-03-26)http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 (required to http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 )Codes specifying the level of confidentiality of the composition. |
Type | code |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
22. Composition.custodian | |
Definition | Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. |
Short | Organization which maintains the composition |
Comments | This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged. |
Control | 0..1 This element is affected by the following invariants: ele-1 |
Type | Reference(Organization) |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | Identifies where to go to find the current version, where to report issues, etc. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ref-1: SHALL have a contained resource if a local reference is provided ( reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) ) |
Guidance on how to interpret the contents of this table can be found here
0. Composition | |||||
Definition | A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition SHALL be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition SHALL be included as subsequent entries in the Bundle, for example Patient, Practitioner, Encounter, etc. | ||||
Short | A set of resources composed into a single coherent clinical statement with clinical attestation | ||||
Comments | While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical. | ||||
Control | 0..* | ||||
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty() )dom-4: 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-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 ( 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-6: A resource should have narrative for robust management ( text.`div`.exists() )dom-5: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty() ) | ||||
2. Composition.id | |||||
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
Short | Logical id of this artifact | ||||
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
Control | 0..1 | ||||
Type | id | ||||
Summary | true | ||||
4. Composition.meta | |||||
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | ||||
Short | Metadata about the resource | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Meta | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
6. Composition.implicitRules | |||||
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | ||||
Short | A set of rules under which this content was created | ||||
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | uri | ||||
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
8. Composition.language | |||||
Definition | The base language in which the resource is written. | ||||
Short | Language of the resource content | ||||
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )A human language.
| ||||
Type | code | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
10. Composition.text | |||||
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | ||||
Short | Text summary of the resource, for human interpretation | ||||
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Narrative | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
12. Composition.contained | |||||
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | ||||
Short | Contained, inline Resources | ||||
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | ||||
Control | 0..* | ||||
Type | Resource | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
14. Composition.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Extension | ||||
Standard Status | Normative (from Trial Use) | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Composition.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
16. Composition.extension:careSettingType | |||||
Slice Name | careSettingType | ||||
Definition | The type of care setting associated with a composition or a list. | ||||
Short | The type of care setting associated with a composition or a list. | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Extension(Extension UK Core Care Setting Type) (Extension Type: CodeableConcept) | ||||
Standard Status | Normative (from Trial Use) | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
18. Composition.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Standard Status | Normative (from Trial Use) | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Composition.modifierExtension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
20. Composition.identifier | |||||
Definition | A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time. | ||||
Short | Version-independent identifier for the Composition | ||||
Comments | Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate. | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Identifier | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
22. Composition.status | |||||
Definition | The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. | ||||
Short | preliminary | final | amended | entered-in-error | ||||
Comments | If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from CompositionStatus (required to http://hl7.org/fhir/ValueSet/composition-status|4.0.1 )The workflow/clinical status of the composition. | ||||
Type | code | ||||
Is Modifier | true because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Need to be able to mark interim, amended, or withdrawn compositions or documents. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
24. Composition.type | |||||
Definition | Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. | ||||
Short | Kind of composition (SNOMED CT) | ||||
Comments | For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHOULD be taken from UK Core Document Type (preferred to https://fhir.hl7.org.uk/ValueSet/UKCore-DocumentType )SNOMED CT Document Type | ||||
Type | CodeableConcept | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Key metadata element describing the composition, used in searching/filtering. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
26. Composition.category | |||||
Definition | A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type. | ||||
Short | Categorization of Composition | ||||
Comments | This is a metadata field from XDS/MHD. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHOULD be taken from UK Core Composition Category (preferred to https://fhir.hl7.org.uk/ValueSet/UKCore-CompositionCategory )A ValueSet to identify the category of a composition. | ||||
Type | CodeableConcept | ||||
Summary | true | ||||
Requirements | Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
28. Composition.subject | |||||
Definition | Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). | ||||
Short | Who and/or what the composition is about | ||||
Comments | For clinical documents, this is usually the patient. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Reference(Resource) | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ref-1: SHALL have a contained resource if a local reference is provided ( reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) ) | ||||
30. Composition.encounter | |||||
Definition | Describes the clinical encounter or type of care this documentation is associated with. | ||||
Short | Context of the Composition | ||||
Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Reference(Encounter) | ||||
Summary | true | ||||
Requirements | Provides context for the composition and supports searching. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ref-1: SHALL have a contained resource if a local reference is provided ( reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) ) | ||||
32. Composition.date | |||||
Definition | The composition editing time, when the composition was last logically changed by the author. | ||||
Short | Composition editing time | ||||
Comments | The Last Modified Date on the composition may be after the date of the document was attested without being changed. | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Type | dateTime | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
34. Composition.author | |||||
Definition | Identifies who is responsible for the information in the composition, not necessarily who typed it in. | ||||
Short | Who and/or what authored the composition | ||||
Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. | ||||
Control | 1..* This element is affected by the following invariants: ele-1 | ||||
Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | true | ||||
Requirements | Identifies who is responsible for the content. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ref-1: SHALL have a contained resource if a local reference is provided ( reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) ) | ||||
36. Composition.title | |||||
Definition | Official human-readable label for the composition. | ||||
Short | Human Readable name/title | ||||
Comments | For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period. | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Type | string | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
38. Composition.confidentiality | |||||
Definition | The code specifying the level of confidentiality of the Composition. | ||||
Short | As defined by affinity domain | ||||
Comments | The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from v3.ConfidentialityClassification (2014-03-26) (required to http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 )Codes specifying the level of confidentiality of the composition. | ||||
Type | code | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
40. Composition.attester | |||||
Definition | A participant who has attested to the accuracy of the composition/document. | ||||
Short | Attests to accuracy of composition | ||||
Comments | Only list each attester once. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | BackboneElement | ||||
Requirements | Identifies responsibility for the accuracy of the composition content. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
42. Composition.attester.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
44. Composition.attester.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Extension | ||||
Standard Status | Normative (from Trial Use) | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Composition.attester.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
46. Composition.attester.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
48. Composition.attester.mode | |||||
Definition | The type of attestation the authenticator offers. | ||||
Short | personal | professional | legal | official | ||||
Comments | Note that FHIR strings SHALL NOT exceed 1MB in size | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from CompositionAttestationMode (required to http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 )The way in which a person authenticated a composition. | ||||
Type | code | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Requirements | Indicates the level of authority of the attestation. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
50. Composition.attester.time | |||||
Definition | When the composition was attested by the party. | ||||
Short | When the composition was attested | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | dateTime | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Requirements | Identifies when the information in the composition was deemed accurate. (Things may have changed since then.). | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
52. Composition.attester.party | |||||
Definition | Who attested the composition in the specified way. | ||||
Short | Who attested the composition | ||||
Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Reference(Patient, RelatedPerson, Practitioner, PractitionerRole, Organization) | ||||
Requirements | Identifies who has taken on the responsibility for accuracy of the composition content. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ref-1: SHALL have a contained resource if a local reference is provided ( reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) ) | ||||
54. Composition.custodian | |||||
Definition | Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. | ||||
Short | Organization which maintains the composition | ||||
Comments | This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Reference(Organization) | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Identifies where to go to find the current version, where to report issues, etc. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ref-1: SHALL have a contained resource if a local reference is provided ( reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) ) | ||||
56. Composition.relatesTo | |||||
Definition | Relationships that this composition has with other compositions or documents that already exist. | ||||
Short | Relationships to other compositions/documents | ||||
Comments | A document is a version specific composition. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | BackboneElement | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
58. Composition.relatesTo.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
60. Composition.relatesTo.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Extension | ||||
Standard Status | Normative (from Trial Use) | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Composition.relatesTo.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
62. Composition.relatesTo.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
64. Composition.relatesTo.code | |||||
Definition | The type of relationship that this composition has with anther composition or document. | ||||
Short | replaces | transforms | signs | appends | ||||
Comments | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from DocumentRelationshipType (required to http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 )The type of relationship between documents. | ||||
Type | code | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
66. Composition.relatesTo.target[x] | |||||
Definition | The target composition/document of this relationship. | ||||
Short | Target of the relationship | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Type | Choice of: Identifier, Reference(Composition) | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
68. Composition.event | |||||
Definition | The clinical service, such as a colonoscopy or an appendectomy, being documented. | ||||
Short | The clinical service(s) being documented | ||||
Comments | The event needs to be consistent with the type element, though can provide further information if desired. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | BackboneElement | ||||
Summary | true | ||||
Requirements | Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
70. Composition.event.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
72. Composition.event.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Extension | ||||
Standard Status | Normative (from Trial Use) | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Composition.event.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
74. Composition.event.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
76. Composition.event.code | |||||
Definition | This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. | ||||
Short | Code(s) that apply to the event being documented | ||||
Comments | An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see v3 Code System ActCode (example to http://terminology.hl7.org/ValueSet/v3-ActCode )This list of codes represents the main clinical acts being documented. | ||||
Type | CodeableConcept | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
78. Composition.event.period | |||||
Definition | The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. | ||||
Short | The period covered by the documentation | ||||
Comments | A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Period | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )per-1: If present, start SHALL have a lower value than end ( start.hasValue().not() or end.hasValue().not() or (start <= end) ) | ||||
80. Composition.event.detail | |||||
Definition | The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. | ||||
Short | The event(s) being documented | ||||
Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Reference(Resource) | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ref-1: SHALL have a contained resource if a local reference is provided ( reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) ) | ||||
82. Composition.section | |||||
Definition | The root of the sections that make up the composition. | ||||
Short | Composition is broken into sections | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | BackboneElement | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )cmp-1: A section must contain at least one of text, entries, or sub-sections ( text.exists() or entry.exists() or section.exists() )cmp-2: A section can only have an emptyReason if it is empty ( emptyReason.empty() or entry.empty() ) | ||||
84. Composition.section.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
86. Composition.section.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Extension | ||||
Standard Status | Normative (from Trial Use) | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Composition.section.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
88. Composition.section.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
90. Composition.section.title | |||||
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | ||||
Short | Label for section (e.g. for ToC) | ||||
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | string | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. | ||||
Alternate Names | header, label, caption | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
92. Composition.section.code | |||||
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title. | ||||
Short | Classification of section (recommended) | ||||
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from UK Core Composition Section Code (extensible to https://fhir.hl7.org.uk/ValueSet/UKCore-CompositionSectionCode )Classification of a section of a composition/document. | ||||
Type | CodeableConcept | ||||
Requirements | Provides computable standardized labels to topics within the document. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
94. Composition.section.author | |||||
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. | ||||
Short | Who and/or what authored the section | ||||
Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Type | Reference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization) | ||||
Requirements | Identifies who is responsible for the content. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ref-1: SHALL have a contained resource if a local reference is provided ( reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) ) | ||||
96. Composition.section.focus | |||||
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | ||||
Short | Who/what the section is about, when it is not about the subject of composition | ||||
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Reference(Resource) | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ref-1: SHALL have a contained resource if a local reference is provided ( reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) ) | ||||
98. Composition.section.text | |||||
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. | ||||
Short | Text summary of the section, for human interpretation | ||||
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1, cmp-1 | ||||
Type | Narrative | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
100. Composition.section.mode | |||||
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | ||||
Short | working | snapshot | changes | ||||
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHALL be taken from ListMode (required to http://hl7.org/fhir/ValueSet/list-mode|4.0.1 )The processing mode that applies to this section. | ||||
Type | code | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
102. Composition.section.orderedBy | |||||
Definition | Specifies the order applied to the items in the section entries. | ||||
Short | Order of section entries | ||||
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHOULD be taken from ListOrderCodes (preferred to http://hl7.org/fhir/ValueSet/list-order )What order applies to the items in the entry. | ||||
Type | CodeableConcept | ||||
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
104. Composition.section.entry | |||||
Definition | A reference to the actual resource from which the narrative in the section is derived. | ||||
Short | A reference to data that supports this section | ||||
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. | ||||
Control | 0..* This element is affected by the following invariants: ele-1, cmp-2 | ||||
Type | Reference(Resource) | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ref-1: SHALL have a contained resource if a local reference is provided ( reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) ) | ||||
106. Composition.section.emptyReason | |||||
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | ||||
Short | Why the section is empty | ||||
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. | ||||
Control | 0..1 This element is affected by the following invariants: ele-1, cmp-2 | ||||
Binding | The codes SHOULD be taken from ListEmptyReasons (preferred to http://hl7.org/fhir/ValueSet/list-empty-reason )If a section is empty, why it is empty. | ||||
Type | CodeableConcept | ||||
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
108. Composition.section.section | |||||
Definition | A nested sub-section within this section. | ||||
Short | Nested Section | ||||
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. | ||||
Control | 0..* This element is affected by the following invariants: cmp-1 | ||||
Type | Seettp://hl7.org/fhir/StructureDefinition/Composition#Composition.section |