HL7 Europe Laboratory Report
2.0.0 - ci-build 150

HL7 Europe Laboratory Report, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/laboratory/ and changes regularly. See the Directory of published versions

Resource Profile: Composition: Laboratory Report

Official URL: http://hl7.eu/fhir/laboratory/StructureDefinition/Composition-eu-lab Version: 2.0.0
Standards status: Trial-use Maturity Level: 2 Computable Name: CompositionLabReportEu

Copyright/Legal: Copyright HL7 Europe. Licensed under creative commons public domain (CC0 1.0).

Clinical document used to represent a Laboratory Report for the scope of the HL7 Europe project.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* CompositionEuCore Laboratory Report composition
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... Slices for extension Content/Rules for all slices
.... extension:version 0..1 (Complex) R5: An explicitly assigned identifer of a variation of the content in the Composition (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
Constraints: ext-1
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version"
.... extension:informationRecipient 0..* (Complex) Composition: Information recipient
URL: http://hl7.eu/fhir/StructureDefinition/information-recipient
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.eu/fhir/StructureDefinition/information-recipient"
.... extension:diagnosticReport 0..1 (Complex) Document DiagnosticReport Reference
URL: http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference"
..... value[x] 1..1 Reference(DiagnosticReport) Value of extension
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... identifier Σ 1..1 Identifier Report identifier
... status ?!Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type Σ 1..1 CodeableConcept Type of (Laboratory) Report
Binding: Laboratory Report Types (preferred)
... Slices for category Σ 0..* CodeableConcept Report Category
Slice: Unordered, Open by value:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:studyType Σ 0..* CodeableConcept The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.)
Binding: Laboratory Study Types (required)
.... category:specialty Σ 0..* CodeableConcept The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry)
Binding: Laboratory Specialty (required)
... subject Σ 1..1 Reference(Patient (EU core) | Group | Location (EU core) | Device) Who and/or what the composition is about
... encounter Σ 0..1 Reference(Encounter) The healthcare event which this Laboratory Report is about (when test ordered).
... date Σ 1..1 dateTime Composition editing time
... author Σ 1..* Reference(Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core) | Device | Patient (EU core) | RelatedPerson) Who and/or what authored the composition
... title Σ 1..1 string Laboratory Report
... Slices for attester 0..* BackboneElement Attests the report accuracy
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code The type of attestation
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
..... time 0..1 dateTime When the report was attested by the party
..... party 0..1 Reference(Patient (EU core) | RelatedPerson | Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core)) Who attested the report
.... attester:legalAuthenticator 0..* BackboneElement Attests to accuracy of composition
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Required Pattern: legal
..... time 1..1 dateTime When the composition was attested
..... party 1..1 Reference(PractitionerRole (EU core) | Practitioner (EU core)) Who attested the composition
.... attester:validator 0..* BackboneElement Attests to accuracy of composition
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Required Pattern: professional
..... time 1..1 dateTime When the composition was attested
..... party 1..1 Reference(PractitionerRole (EU core) | Practitioner (EU core)) Who attested the composition
... event Σ 0..* BackboneElement The laboratory service(s) being documented
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 0..* CodeableConcept Code(s) that apply to the laboratory service(s) being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period Period of time covered by the documentation
.... detail Σ 0..* Reference(Resource) The laboratory service(s) being documented
... Slices for section C 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by pattern:$this.code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string Label for section (e.g. for ToC)
..... code 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... text C 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:annotations C 0..* BackboneElement Annotation comment
Constraints: cmp-1, cmp-2
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string Label for section (e.g. for ToC)
..... code 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48767-8
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:attachment C 0..* BackboneElement Additional data (like images, diagrams) associated with this report
Constraints: cmp-1, cmp-2
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string Label for section (e.g. for ToC)
..... code 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 77599-9
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry C 1..* Reference(Binary | DocumentReference) A reference to data that supports this section

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred Laboratory Report Types 📦2.0.0 This IG
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.category:studyType Base required Laboratory Study Types 📦2.0.0 This IG
Composition.category:specialty Base required Laboratory Specialty 📦2.0.0 This IG
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legalAuthenticator.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:validator.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.event.code Base example v3 Code System ActCode 📦3.0.0 THO v7.1
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:annotations.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:attachment.​code Base example Document Section Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section, Composition.section:annotations, Composition.section:attachment A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section, Composition.section:annotations, Composition.section:attachment A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Composition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error Composition.extension:version, Composition.extension:informationRecipient, Composition.extension:diagnosticReport, Composition.modifierExtension, Composition.attester.modifierExtension, Composition.attester:legalAuthenticator.modifierExtension, Composition.attester:validator.modifierExtension, Composition.event.modifierExtension, Composition.section.extension:section-note, Composition.section.modifierExtension, Composition.section:annotations.extension:section-note, Composition.section:annotations.modifierExtension, Composition.section:attachment.extension:section-note, Composition.section:attachment.modifierExtension Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from CompositionEuCore

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* CompositionEuCore Laboratory Report composition
... text 0..1 Narrative Narrative text
... Slices for extension Content/Rules for all slices
.... extension:diagnosticReport 0..1 DiagnosticReportReference Document DiagnosticReport Reference
..... value[x] 1..1 Reference(DiagnosticReport) Value of extension
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
... identifier 1..1 Identifier Report identifier
... Slices for category 0..* CodeableConcept Report Category
Slice: Unordered, Open by value:$this
.... category:studyType 0..* CodeableConcept The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.)
Binding: Laboratory Study Types (required)
.... category:specialty 0..* CodeableConcept The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry)
Binding: Laboratory Specialty (required)
... subject 1..1 Reference(Patient (EU core) | Group | Location (EU core) | Device) Who and/or what the composition is about
... encounter 0..1 Reference(Encounter) The healthcare event which this Laboratory Report is about (when test ordered).
... author 1..* Reference(Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core) | Device | Patient (EU core) | RelatedPerson) Who and/or what authored the composition
... title 1..1 string Laboratory Report
... attester 0..* BackboneElement Attests the report accuracy
.... mode 1..1 code The type of attestation
.... time 0..1 dateTime When the report was attested by the party
.... party 0..1 Reference(Patient (EU core) | RelatedPerson | Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core)) Who attested the report
... event 0..* BackboneElement The laboratory service(s) being documented
.... code 0..* CodeableConcept Code(s) that apply to the laboratory service(s) being documented
.... period 0..1 Period Period of time covered by the documentation
.... detail 0..* Reference(Resource) The laboratory service(s) being documented
... Slices for section 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by pattern:$this.code
.... section:annotations 0..* BackboneElement Annotation comment
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48767-8
..... entry 0..0 A reference to data that supports this section
..... section 0..0 Nested Section
.... section:attachment 0..* BackboneElement Additional data (like images, diagrams) associated with this report
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 77599-9
..... entry 1..* Reference(Binary | DocumentReference) A reference to data that supports this section
..... section 0..0 Nested Section

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Composition.type Base preferred Laboratory Report Types 📦2.0.0 This IG
Composition.category:studyType Base required Laboratory Study Types 📦2.0.0 This IG
Composition.category:specialty Base required Laboratory Specialty 📦2.0.0 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* CompositionEuCore Laboratory Report composition
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:version 0..1 (Complex) R5: An explicitly assigned identifer of a variation of the content in the Composition (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
Constraints: ext-1
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version"
..... value[x] 0..1 string An explicitly assigned identifer of a variation of the content in the Composition
.... extension:informationRecipient 0..* (Complex) Composition: Information recipient
URL: http://hl7.eu/fhir/StructureDefinition/information-recipient
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.eu/fhir/StructureDefinition/information-recipient"
..... value[x] 0..1 Reference(Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core) | Device | Patient (EU core) | RelatedPerson) Value of extension
.... extension:diagnosticReport 0..1 (Complex) Document DiagnosticReport Reference
URL: http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference"
..... value[x] 1..1 Reference(DiagnosticReport) Value of extension
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 1..1 Identifier Report identifier
... status ?!Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type Σ 1..1 CodeableConcept Type of (Laboratory) Report
Binding: Laboratory Report Types (preferred)
... Slices for category Σ 0..* CodeableConcept Report Category
Slice: Unordered, Open by value:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:studyType Σ 0..* CodeableConcept The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.)
Binding: Laboratory Study Types (required)
.... category:specialty Σ 0..* CodeableConcept The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry)
Binding: Laboratory Specialty (required)
... subject Σ 1..1 Reference(Patient (EU core) | Group | Location (EU core) | Device) Who and/or what the composition is about
... encounter Σ 0..1 Reference(Encounter) The healthcare event which this Laboratory Report is about (when test ordered).
... date Σ 1..1 dateTime Composition editing time
... author Σ 1..* Reference(Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core) | Device | Patient (EU core) | RelatedPerson) Who and/or what authored the composition
... title Σ 1..1 string Laboratory Report
... confidentiality Σ 0..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... Slices for attester 0..* BackboneElement Attests the report accuracy
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code The type of attestation
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
..... time 0..1 dateTime When the report was attested by the party
..... party 0..1 Reference(Patient (EU core) | RelatedPerson | Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core)) Who attested the report
.... attester:legalAuthenticator 0..* BackboneElement Attests to accuracy of composition
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Required Pattern: legal
..... time 1..1 dateTime When the composition was attested
..... party 1..1 Reference(PractitionerRole (EU core) | Practitioner (EU core)) Who attested the composition
.... attester:validator 0..* BackboneElement Attests to accuracy of composition
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Required Pattern: professional
..... time 1..1 dateTime When the composition was attested
..... party 1..1 Reference(PractitionerRole (EU core) | Practitioner (EU core)) Who attested the composition
... custodian Σ 0..1 Reference(Organization (EU core)) Organization which maintains the composition
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The laboratory service(s) being documented
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 0..* CodeableConcept Code(s) that apply to the laboratory service(s) being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period Period of time covered by the documentation
.... detail Σ 0..* Reference(Resource) The laboratory service(s) being documented
... Slices for section C 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by pattern:$this.code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string Label for section (e.g. for ToC)
..... code 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Empty reason
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:annotations C 0..* BackboneElement Annotation comment
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string Label for section (e.g. for ToC)
..... code 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48767-8
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... emptyReason C 0..1 CodeableConcept Empty reason
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:attachment C 0..* BackboneElement Additional data (like images, diagrams) associated with this report
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string Label for section (e.g. for ToC)
..... code 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 77599-9
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 1..* Reference(Binary | DocumentReference) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Empty reason
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Composition.extension:diagnosticReport.​value[x].type Base extensible ResourceType 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred Laboratory Report Types 📦2.0.0 This IG
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.category:studyType Base required Laboratory Study Types 📦2.0.0 This IG
Composition.category:specialty Base required Laboratory Specialty 📦2.0.0 This IG
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legalAuthenticator.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:validator.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.event.code Base example v3 Code System ActCode 📦3.0.0 THO v7.1
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:annotations.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:annotations.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:annotations.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:annotations.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:attachment.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:attachment.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:attachment.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:attachment.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section, Composition.section:annotations, Composition.section:attachment A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section, Composition.section:annotations, Composition.section:attachment A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Composition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from CompositionEuCore

Summary

Mandatory: 1 element(3 nested mandatory elements)
Prohibited: 3 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Composition.category
  • The element 1 is sliced based on the value of Composition.section

Maturity: 2

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* CompositionEuCore Laboratory Report composition
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... Slices for extension Content/Rules for all slices
.... extension:version 0..1 (Complex) R5: An explicitly assigned identifer of a variation of the content in the Composition (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
Constraints: ext-1
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version"
.... extension:informationRecipient 0..* (Complex) Composition: Information recipient
URL: http://hl7.eu/fhir/StructureDefinition/information-recipient
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.eu/fhir/StructureDefinition/information-recipient"
.... extension:diagnosticReport 0..1 (Complex) Document DiagnosticReport Reference
URL: http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference"
..... value[x] 1..1 Reference(DiagnosticReport) Value of extension
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... identifier Σ 1..1 Identifier Report identifier
... status ?!Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type Σ 1..1 CodeableConcept Type of (Laboratory) Report
Binding: Laboratory Report Types (preferred)
... Slices for category Σ 0..* CodeableConcept Report Category
Slice: Unordered, Open by value:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:studyType Σ 0..* CodeableConcept The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.)
Binding: Laboratory Study Types (required)
.... category:specialty Σ 0..* CodeableConcept The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry)
Binding: Laboratory Specialty (required)
... subject Σ 1..1 Reference(Patient (EU core) | Group | Location (EU core) | Device) Who and/or what the composition is about
... encounter Σ 0..1 Reference(Encounter) The healthcare event which this Laboratory Report is about (when test ordered).
... date Σ 1..1 dateTime Composition editing time
... author Σ 1..* Reference(Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core) | Device | Patient (EU core) | RelatedPerson) Who and/or what authored the composition
... title Σ 1..1 string Laboratory Report
... Slices for attester 0..* BackboneElement Attests the report accuracy
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code The type of attestation
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
..... time 0..1 dateTime When the report was attested by the party
..... party 0..1 Reference(Patient (EU core) | RelatedPerson | Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core)) Who attested the report
.... attester:legalAuthenticator 0..* BackboneElement Attests to accuracy of composition
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Required Pattern: legal
..... time 1..1 dateTime When the composition was attested
..... party 1..1 Reference(PractitionerRole (EU core) | Practitioner (EU core)) Who attested the composition
.... attester:validator 0..* BackboneElement Attests to accuracy of composition
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Required Pattern: professional
..... time 1..1 dateTime When the composition was attested
..... party 1..1 Reference(PractitionerRole (EU core) | Practitioner (EU core)) Who attested the composition
... event Σ 0..* BackboneElement The laboratory service(s) being documented
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 0..* CodeableConcept Code(s) that apply to the laboratory service(s) being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period Period of time covered by the documentation
.... detail Σ 0..* Reference(Resource) The laboratory service(s) being documented
... Slices for section C 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by pattern:$this.code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string Label for section (e.g. for ToC)
..... code 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... text C 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:annotations C 0..* BackboneElement Annotation comment
Constraints: cmp-1, cmp-2
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string Label for section (e.g. for ToC)
..... code 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48767-8
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:attachment C 0..* BackboneElement Additional data (like images, diagrams) associated with this report
Constraints: cmp-1, cmp-2
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string Label for section (e.g. for ToC)
..... code 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 77599-9
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text C 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry C 1..* Reference(Binary | DocumentReference) A reference to data that supports this section

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred Laboratory Report Types 📦2.0.0 This IG
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.category:studyType Base required Laboratory Study Types 📦2.0.0 This IG
Composition.category:specialty Base required Laboratory Specialty 📦2.0.0 This IG
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legalAuthenticator.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:validator.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.event.code Base example v3 Code System ActCode 📦3.0.0 THO v7.1
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:annotations.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:attachment.​code Base example Document Section Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section, Composition.section:annotations, Composition.section:attachment A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section, Composition.section:annotations, Composition.section:attachment A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Composition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error Composition.extension:version, Composition.extension:informationRecipient, Composition.extension:diagnosticReport, Composition.modifierExtension, Composition.attester.modifierExtension, Composition.attester:legalAuthenticator.modifierExtension, Composition.attester:validator.modifierExtension, Composition.event.modifierExtension, Composition.section.extension:section-note, Composition.section.modifierExtension, Composition.section:annotations.extension:section-note, Composition.section:annotations.modifierExtension, Composition.section:attachment.extension:section-note, Composition.section:attachment.modifierExtension Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

This structure is derived from CompositionEuCore

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* CompositionEuCore Laboratory Report composition
... text 0..1 Narrative Narrative text
... Slices for extension Content/Rules for all slices
.... extension:diagnosticReport 0..1 DiagnosticReportReference Document DiagnosticReport Reference
..... value[x] 1..1 Reference(DiagnosticReport) Value of extension
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
... identifier 1..1 Identifier Report identifier
... Slices for category 0..* CodeableConcept Report Category
Slice: Unordered, Open by value:$this
.... category:studyType 0..* CodeableConcept The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.)
Binding: Laboratory Study Types (required)
.... category:specialty 0..* CodeableConcept The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry)
Binding: Laboratory Specialty (required)
... subject 1..1 Reference(Patient (EU core) | Group | Location (EU core) | Device) Who and/or what the composition is about
... encounter 0..1 Reference(Encounter) The healthcare event which this Laboratory Report is about (when test ordered).
... author 1..* Reference(Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core) | Device | Patient (EU core) | RelatedPerson) Who and/or what authored the composition
... title 1..1 string Laboratory Report
... attester 0..* BackboneElement Attests the report accuracy
.... mode 1..1 code The type of attestation
.... time 0..1 dateTime When the report was attested by the party
.... party 0..1 Reference(Patient (EU core) | RelatedPerson | Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core)) Who attested the report
... event 0..* BackboneElement The laboratory service(s) being documented
.... code 0..* CodeableConcept Code(s) that apply to the laboratory service(s) being documented
.... period 0..1 Period Period of time covered by the documentation
.... detail 0..* Reference(Resource) The laboratory service(s) being documented
... Slices for section 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by pattern:$this.code
.... section:annotations 0..* BackboneElement Annotation comment
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48767-8
..... entry 0..0 A reference to data that supports this section
..... section 0..0 Nested Section
.... section:attachment 0..* BackboneElement Additional data (like images, diagrams) associated with this report
..... code 1..1 CodeableConcept Classification of section (recommended)
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 77599-9
..... entry 1..* Reference(Binary | DocumentReference) A reference to data that supports this section
..... section 0..0 Nested Section

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Composition.type Base preferred Laboratory Report Types 📦2.0.0 This IG
Composition.category:studyType Base required Laboratory Study Types 📦2.0.0 This IG
Composition.category:specialty Base required Laboratory Specialty 📦2.0.0 This IG

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* CompositionEuCore Laboratory Report composition
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:version 0..1 (Complex) R5: An explicitly assigned identifer of a variation of the content in the Composition (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
Constraints: ext-1
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version"
..... value[x] 0..1 string An explicitly assigned identifer of a variation of the content in the Composition
.... extension:informationRecipient 0..* (Complex) Composition: Information recipient
URL: http://hl7.eu/fhir/StructureDefinition/information-recipient
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.eu/fhir/StructureDefinition/information-recipient"
..... value[x] 0..1 Reference(Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core) | Device | Patient (EU core) | RelatedPerson) Value of extension
.... extension:diagnosticReport 0..1 (Complex) Document DiagnosticReport Reference
URL: http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference"
..... value[x] 1..1 Reference(DiagnosticReport) Value of extension
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 1..1 Identifier Report identifier
... status ?!Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type Σ 1..1 CodeableConcept Type of (Laboratory) Report
Binding: Laboratory Report Types (preferred)
... Slices for category Σ 0..* CodeableConcept Report Category
Slice: Unordered, Open by value:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:studyType Σ 0..* CodeableConcept The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.)
Binding: Laboratory Study Types (required)
.... category:specialty Σ 0..* CodeableConcept The clinical domain of the laboratory performing the observation (e.g. microbiology, toxicology, chemistry)
Binding: Laboratory Specialty (required)
... subject Σ 1..1 Reference(Patient (EU core) | Group | Location (EU core) | Device) Who and/or what the composition is about
... encounter Σ 0..1 Reference(Encounter) The healthcare event which this Laboratory Report is about (when test ordered).
... date Σ 1..1 dateTime Composition editing time
... author Σ 1..* Reference(Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core) | Device | Patient (EU core) | RelatedPerson) Who and/or what authored the composition
... title Σ 1..1 string Laboratory Report
... confidentiality Σ 0..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... Slices for attester 0..* BackboneElement Attests the report accuracy
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code The type of attestation
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
..... time 0..1 dateTime When the report was attested by the party
..... party 0..1 Reference(Patient (EU core) | RelatedPerson | Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core)) Who attested the report
.... attester:legalAuthenticator 0..* BackboneElement Attests to accuracy of composition
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Required Pattern: legal
..... time 1..1 dateTime When the composition was attested
..... party 1..1 Reference(PractitionerRole (EU core) | Practitioner (EU core)) Who attested the composition
.... attester:validator 0..* BackboneElement Attests to accuracy of composition
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Required Pattern: professional
..... time 1..1 dateTime When the composition was attested
..... party 1..1 Reference(PractitionerRole (EU core) | Practitioner (EU core)) Who attested the composition
... custodian Σ 0..1 Reference(Organization (EU core)) Organization which maintains the composition
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The laboratory service(s) being documented
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 0..* CodeableConcept Code(s) that apply to the laboratory service(s) being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period Period of time covered by the documentation
.... detail Σ 0..* Reference(Resource) The laboratory service(s) being documented
... Slices for section C 1..* BackboneElement Composition is broken into sections
Slice: Unordered, Open by pattern:$this.code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string Label for section (e.g. for ToC)
..... code 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 0..* Reference(Resource) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Empty reason
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
..... section C 0..* See section (Composition) Nested Section
.... section:annotations C 0..* BackboneElement Annotation comment
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string Label for section (e.g. for ToC)
..... code 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48767-8
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... emptyReason C 0..1 CodeableConcept Empty reason
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section:attachment C 0..* BackboneElement Additional data (like images, diagrams) associated with this report
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:section-note 0..* Annotation Additional notes that apply to the section (but not to specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title 1..1 string Label for section (e.g. for ToC)
..... code 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 77599-9
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text C 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
..... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
..... entry C 1..* Reference(Binary | DocumentReference) A reference to data that supports this section
..... emptyReason C 0..1 CodeableConcept Empty reason
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Composition.extension:diagnosticReport.​value[x].type Base extensible ResourceType 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred Laboratory Report Types 📦2.0.0 This IG
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.category:studyType Base required Laboratory Study Types 📦2.0.0 This IG
Composition.category:specialty Base required Laboratory Specialty 📦2.0.0 This IG
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legalAuthenticator.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:validator.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.event.code Base example v3 Code System ActCode 📦3.0.0 THO v7.1
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:annotations.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:annotations.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:annotations.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:annotations.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.
Composition.section:attachment.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section:attachment.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:attachment.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section:attachment.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section, Composition.section:annotations, Composition.section:attachment A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section, Composition.section:annotations, Composition.section:attachment A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Composition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from CompositionEuCore

Summary

Mandatory: 1 element(3 nested mandatory elements)
Prohibited: 3 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Composition.category
  • The element 1 is sliced based on the value of Composition.section

Maturity: 2

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Section Modeling Variants

The profile allows both section modeling variants:

  1. Top-level section(s) with direct entry elements (no sub-sections)
  2. Top-level section(s) that contain nested sub-sections

Example with sub-sections:

Example without sub-sections: