AU Patient Summary Composition. A composition is a set of healthcare-related information that is assembled together into a single logical document 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. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.

• Composition (IPS)

The conformance of this Composition to a specific version of a Patient Summary specification (e.g. AU PS 1.0.0 conformance claim http://hl7.org.au/fhir/ps/StructureDefinition/au-ps-composition|1.0.0, IPS 2.0.0 conformance claim http://hl7.org/fhir/uv/ips/StructureDefinition/Composition-uv-ips|2.0.0)

Specifies that this composition refers to a Patient Summary (Loinc "60591-5")

Who or what the composition is about. In general a 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). For the AU PS the subject is always the patient.

Identifies who is responsible for the information in the patient summary, not necessarily who typed it in.

The type of author(s) contribute to determine the "nature"of the patient summary: e.g. a "human-curated" Vs. "automatically generated".

Official human-readable label for the composition.

For this document the title would likely include the text "Patient Summary" or any equivalent translation and other relevant document information.This can include information like the patient name and time generated.

The main activity being described by a patient summary is the provision of healthcare over a period of time. In the CDA representation of the IPS this is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. In the FHIR representation at least one event will be used to record this information. Additional data from outside this duration can also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). For example if the patient summary is generated by a GP, based on information recorded in his/her EHR-S, then the start value will represent the date when the treatment relationship between the patient and the GP started; and the end value the date of the latest care event.

The provision of healthcare over a period of time this patient summary is documenting.

The root of the sections that make up the patient summary composition.

Additional notes that apply to the section (but not to specific resource).

Information about a patient's clinical problems or conditions that are currently being monitored.

The clinical problems or conditions currently being monitored for the patient. An entry can be used to document that no information about problems is available, or that no relevant problems are known.

Information about a patient's relevant allergies or intolerances, describing the kind of reaction (e.g. rash, anaphylaxis, etc.); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, this section will list currently active and any relevant historical allergies and adverse reactions. If no information about allergies is available, or if no allergies are known this is to be clearly documented in this section.

The relevant allergies or intolerances (conditions) for that patient, describing the kind of reaction (e.g. rash, anaphylaxis, etc.); preferably the agents that cause it; and optionally the criticality and the certainty of the allergy. At a minimum, will include currently active and any relevant historical allergies and adverse reactions. An entry can be used to document that no information about allergies is available, or that no allergies are known.

Information about a patient's medications relevant for the scope of the patient summary. The actual content could depend on the jurisdiction, it could report: - the currently active medications; - the current and past medications considered relevant by the authoring GP; - the patient prescriptions or dispensations automatically extracted by a regional or a national EHR. In those cases medications are documented in the Patient Summary as medication statements or medication requests. This section requires either an entry indicating the subject is known not to be on any relevant medication; either an entry indicating that no information is available about medications; or entries summarising the subject's relevant medications.

The medications relevant for the scope of the patient summary, or an indication that the subject is known not to be on any relevant medication; either that no information is available about medications.

Information about a patient's current immunisation status and pertinent immunisation history. The primary use case for this section is to enable communication of a patient's immunisation status. It could contain the entire immunisation history that is relevant to the period of time being summarised. This entry is used to document that no information about immunisations is available, or that no immunisations are known.

The patient's current immunisation status and pertinent immunisation history. The primary use case is to enable communication of a patient's immunisation status. It can contain the entire immunisation history relevant to the period of time being summarised. An entry can be used to document that no information about immunisations is available, or that no immunisations are known.

Information about a patient's relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some of these results could be laboratory results, others could be anatomic pathology results, others could be radiology results, and others could be clinical results.

The relevant observation results collected on the patient or produced on in-vitro biologic specimens collected from the patient. Some results could be laboratory results, others could be anatomic pathology results, others could be radiology results, and others could be clinical results.

Information about a patient's past procedures that are pertinent to the scope of this patient summary. Procedures could refer, for example to:

1. Invasive Diagnostic procedure: e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)
2. Therapeutic procedure: e.g. dialysis;
3. Surgical procedure: e.g. appendectomy

The patient's past procedures that are pertinent to the scope of this patient summary. Procedures can refer for example to:

1. Invasive Diagnostic procedure: e.g. Cardiac catheterization; (the results of these procedure are documented in the results section)
2. Therapeutic procedure: e.g. dialysis;
3. Surgical procedure: e.g. appendectomy. An entry can be used to document that no information about past procedures is available, or that no relevant past procedures are known.

Information about a patient's history of medical device use.

The patient's history of medical device use. An entry can be used to document that no information about medical device use is available, or that no relevant medical device use is known.

Information about a patient's advance directives.

The patient's advance directive.

Information about a patient's alerts pertinent to the scope of the patient summary including flagging potential concerns and/or dangers to/from the patient and can also include obstacles to care.

The alert information to be communicated; can optionally reference other resources in the patient summary.

Information about a patient's functional status including a description of capability of the patient to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status can in fact influence decisions about how to administer treatments. Profiles to express disabilities and functional assessments will be specified by future versions of this guide.

The patient's capability to perform acts of daily living, including possible needs of the patient to be continuously assessed by third parties. The invalidity status can in fact influence decisions about how to administer treatments. Profiles to express disabilities and functional assessments are expected be specified by future versions of this guide.

Information about a patient's conditions that were suffered in the past and are no longer tracked in the Problem List.

The conditions the patient suffered in the past and are no longer tracked in the Problem List.

Information about whether a patient is currently pregnant or not and can contain addition summarising information about the outcome of earlier pregnancies.

Information about whether the patient is currently pregnant or not. It can contain addition summarising information about the outcome of earlier pregnancies.

Information about what matters to a patient. This can include needs, strengths, values, concerns and preferences to others providing support and care. The patient's story, provided here, can be told by the patient or by a proxy.

The information about what matters to a patient. This can include needs, strengths, values, concerns and preferences to others providing support and care.

Information about a patient's plans of care containing the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient.

The dynamic, personalised care plans including identified needed healthcare activity, health objectives and healthcare goals, relating to one or more specified health issues in a healthcare process [Source EN ISO 13940]

Information about a patient's health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits, alcohol consumption, diets, risky habits.)

The patient's health related "lifestyle factors" or "lifestyle observations" (e.g. smoke habits, alcohol consumption, diets, risky habits.)

Information about a patient's vital signs including blood pressure, body temperature, heart rate, and respiratory rate. It can also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends can be included

The notable vital signs or physical findings as: blood pressure, body temperature, heart rate, and respiratory rate. It can also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends can be included

AU Patient Summary Composition. A composition is a set of healthcare-related information that is assembled together into a single logical document 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. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.

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.

• Composition (IPS)

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.

The conformance of this Composition to a specific version of a Patient Summary specification (e.g. AU PS 1.0.0 conformance claim http://hl7.org.au/fhir/ps/StructureDefinition/au-ps-composition|1.0.0, IPS 2.0.0 conformance claim http://hl7.org/fhir/uv/ips/StructureDefinition/Composition-uv-ips|2.0.0)

It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

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.

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.

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.

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.

A recipient who should receive a copy of the composition. A recipient is an entity to whom a copy of the composition is directed at the time of authoring of the composition.

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).

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.

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.

A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.

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.

The workflow/clinical status of the composition.

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Specifies that this composition refers to a Patient Summary (Loinc "60591-5")

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.

Type of a composition.

Key metadata element describing the composition, used in searching/filtering.

Who or what the composition is about. In general a 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). For the AU PS the subject is always the patient.

For clinical documents, this is usually the patient.

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

The composition editing time, when the composition was last logically changed by the author.

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

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.

Identifies who is responsible for the information in the patient summary, not necessarily who typed it in.

The type of author(s) contribute to determine the "nature"of the patient summary: e.g. a "human-curated" Vs. "automatically generated".

Identifies who is responsible for the content.

Official human-readable label for the composition.

For this document the title would likely include the text "Patient Summary" or any equivalent translation and other relevant document information.This can include information like the patient name and time generated.

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.

A participant who has attested to the accuracy of the composition/document.

Only list each attester once.

Identifies responsibility for the accuracy of the composition content.

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).

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.

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.

The type of attestation the authenticator offers.

The way in which a person authenticated a composition.

Indicates the level of authority of the attestation.

When the composition was attested by the party.

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Who attested the composition in the specified way.

Identifies who has taken on the responsibility for accuracy of the composition content.

Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.

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.

Identifies where to go to find the current version, where to report issues, etc.

Relationships that this composition has with other compositions or documents that already exist.

A document is a version specific composition.

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).

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.

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.

The type of relationship that this composition has with anther composition or document.

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

The type of relationship between documents.

The target composition/document of this relationship.

The main activity being described by a patient summary is the provision of healthcare over a period of time. In the CDA representation of the IPS this is shown by setting the value of serviceEvent/@classCode to “PCPR” (care provision) and indicating the duration over which care was provided in serviceEvent/effectiveTime. In the FHIR representation at least one event will be used to record this information. Additional data from outside this duration can also be included if it is relevant to care provided during that time range (e.g., reviewed during the stated time range). For example if the patient summary is generated by a GP, based on information recorded in his/her EHR-S, then the start value will represent the date when the treatment relationship between the patient and the GP started; and the end value the date of the latest care event.

The event needs to be consistent with the type element, though can provide further information if desired.

Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.

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).

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.

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.

The provision of healthcare over a period of time this patient summary is documenting.

The event needs to be consistent with the type element, though can provide further information if desired.

Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.

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).

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.

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.

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.

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.

This list of codes represents the main clinical acts being documented.