Australian Base Implementation Guide (AU Base 2)

AU Base Implementation Guide, published by HL7 Australia. This is not an authorized publication; it is the continuous build for version 2.2.0). This version is based on the current content of https://github.com/ci-collaborative/au-fhir-base-r4/ and changes regularly. See the Directory of published versions

1.0 StructureDefinition-au-composition

AU Composition [FMM Level 2]

This profile defines a composition structure that includes core localisation concepts for use in an Australian context.

Usage Notes

When capturing a composition practitioner role as the sole author of the composition, a practitioner linked to that practitioner role is required to be supplied as a composition author. Where there is more than one author this is not necessary or recommended.

Where practicable it is preferred that the assertion of clinical judgement that there are no known items for this list is handled via an entry with the appropriate negation code over making use of section emptyReason. For example the instantiation of an AllergyIntolerance with code that is a child of 716186003 |No known allergy| from SNOMED CT[1].

Extensions

Extensions used in this profile:

  • Composition: Information Recipient[1]

Conversion

NOTE: AU Base on STU3 included three extensions Composition Author Role, Related Person Attester Party, andRelated Person Attester Party which are now no longer required as direct R4 support is available.

Examples

Composition with multiple information recipients

Composition with some sections having a different section author to the composition author

Patient’s preference upon death

1.0.1 Formal Views of Profile Content

The official URL for this profile is:

http://hl7.org.au/fhir/StructureDefinition/au-composition

This profile defines a composition structure that includes core localisation concepts for use in an Australian context.

This profile builds on Composition.

This profile was published on Wed Jul 15 00:00:00 UTC 2020 as a draft by Health Level Seven Australia (Patient Administration WG).

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionComposition for the Australian realm
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... information-recipient 0..*Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization)Who and/or what should receive a copy of the composition
URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierVersion-independent identifier for the Composition
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type Σ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.

... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject Σ0..1Reference(Resource)Who and/or what the composition is about
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date Σ1..1dateTimeComposition editing time
... author Σ1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the composition
... title Σ1..1stringHuman Readable name/title
... confidentiality Σ0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

... attester 0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(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 Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section I0..*BackboneElementComposition is broken into sections
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

.... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

.... section I0..*See section (Composition)Nested Section

doco Documentation for this format

Differential View

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionComposition for the Australian realm
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... information-recipient 0..*Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization)Who and/or what should receive a copy of the composition
URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierVersion-independent identifier for the Composition
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type Σ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.

... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject Σ0..1Reference(Resource)Who and/or what the composition is about
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date Σ1..1dateTimeComposition editing time
... author Σ1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the composition
... title Σ1..1stringHuman Readable name/title
... confidentiality Σ0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

... attester 0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(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 Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section I0..*BackboneElementComposition is broken into sections
cmp-1: A section must contain at least one of text, entries, or sub-sections
cmp-2: A section can only have an emptyReason if it is empty
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

.... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

.... section I0..*See section (Composition)Nested Section

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

 

1.0.2 Quick Start

Below is an overview of the required search and read operations.

Summary of Search Criteria for StructureDefinition-au-composition

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