ImplementationGuide for Malaysia Core (MY Core), published by Malaysia Healthcare Nexus (MHN). This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/nhphong245/my-core-ig-r4/ and changes regularly. See the Directory of published versions

• Content
• Detailed Descriptions
• XML
• JSON

Resource Profile: Composition (MY Core)

Official URL: http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core				Version: 0.0.1
Active as of 2024-03-13		Responsible: Malaysia Healthcare Nexus (MHN)	Realm:	Computable Name: CompositionMyCore

Composition profile for general composition use

Usage:

• This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

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

This structure is derived from Composition

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
Slices for extension				Content/Rules for all slices
locationRecorded		0..1	Reference(Location) {r}	An extension to define where the Composition was recorded (Location Resource) URL: http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
type		1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: ValueSetCompositionType (MY Core) (extensible)
Slices for category		1..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system
category:category		0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionCategory (MY Core) (example)
coding
system		0..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core
category:class		0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example)
coding
system		0..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-class-my-core
subject		1..1	Reference(Patient)	Who and/or what the composition is about
confidentiality		0..1	code	As defined by affinity domain Binding: V3 Value SetConfidentialityClassification (required)
custodian		1..1	Reference(Organization)	Organization which maintains the composition
event		1..*	BackboneElement	The clinical service(s) being documented
code		0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: ValueSetCompositionEvent (MY Core) (extensible)
section		1..*	BackboneElement	Composition is broken into sections
Slices for extension				Content/Rules for all slices
sectionDate		0..1	dateTime	Extension to define the date this section was created on URL: http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core
code		1..1	CodeableConcept	Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.type	extensible	ValueSetCompositionTypeMyCore (a valid code from CodeSystemCompositionType (MY Core)) http://fhir.hie.moh.gov.my/ValueSet/composition-type-my-core from this IG
Composition.category:category	example	ValueSetCompositionCategoryMyCore (a valid code from CodeSystemCompositionCategory (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-core from this IG
Composition.category:class	example	ValueSetCompositionClassMyCore (a valid code from CodeSystemCompositionClass (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-core from this IG
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.event.code	extensible	ValueSetCompositionEventMyCore (a valid code from CodeSystemCompositionEvent (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-event-my-core from this IG
Composition.section.code	example	ValueSetCompositionSectionMyCore http://fhir.hie.moh.gov.my/ValueSet/composition-section-my-core from this IG

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension				Content/Rules for all slices
locationRecorded		0..1	Reference(Location) {r}	An extension to define where the Composition was recorded (Location Resource) URL: http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
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	Kind of composition (LOINC if possible) Binding: ValueSetCompositionType (MY Core) (extensible)
Slices for category	Σ	1..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:category	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionCategory (MY Core) (example)
category:class	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example)
subject	Σ	1..1	Reference(Patient)	Who and/or what the composition is about
date	Σ	1..1	dateTime	Composition editing time
author	Σ	1..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the composition
title	Σ	1..1	string	Human Readable name/title
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: V3 Value SetConfidentialityClassification (required)
custodian	Σ	1..1	Reference(Organization)	Organization which maintains the composition
event	Σ	1..*	BackboneElement	The clinical 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 event being documented Binding: ValueSetCompositionEvent (MY Core) (extensible)
section	C	1..*	BackboneElement	Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
Slices for extension				Content/Rules for all slices
sectionDate		0..1	dateTime	Extension to define the date this section was created on URL: http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	ValueSetCompositionTypeMyCore (a valid code from CodeSystemCompositionType (MY Core)) http://fhir.hie.moh.gov.my/ValueSet/composition-type-my-core from this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.category:category	example	ValueSetCompositionCategoryMyCore (a valid code from CodeSystemCompositionCategory (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-core from this IG
Composition.category:class	example	ValueSetCompositionClassMyCore (a valid code from CodeSystemCompositionClass (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-core from this IG
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.event.code	extensible	ValueSetCompositionEventMyCore (a valid code from CodeSystemCompositionEvent (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-event-my-core from this IG
Composition.section.code	example	ValueSetCompositionSectionMyCore http://fhir.hie.moh.gov.my/ValueSet/composition-section-my-core from this IG

Constraints

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

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
locationRecorded		0..1	Reference(Location) {r}	An extension to define where the Composition was recorded (Location Resource) URL: http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Version-independent identifier for the Composition
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	Kind of composition (LOINC if possible) Binding: ValueSetCompositionType (MY Core) (extensible)
Slices for category	Σ	1..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:category	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionCategory (MY Core) (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category:class	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-class-my-core
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subject	Σ	1..1	Reference(Patient)	Who and/or what the composition is about
encounter	Σ	0..1	Reference(Encounter)	Context of the Composition
date	Σ	1..1	dateTime	Composition editing time
author	Σ	1..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the composition
title	Σ	1..1	string	Human Readable name/title
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: V3 Value SetConfidentialityClassification (required)
attester		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.
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)	Who attested the composition
custodian	Σ	1..1	Reference(Organization)	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	1..*	BackboneElement	The clinical service(s) being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: ValueSetCompositionEvent (MY Core) (extensible)
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
section	C	1..*	BackboneElement	Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
sectionDate		0..1	dateTime	Extension to define the date this section was created on URL: http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example)
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
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	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	ValueSetCompositionTypeMyCore (a valid code from CodeSystemCompositionType (MY Core)) http://fhir.hie.moh.gov.my/ValueSet/composition-type-my-core from this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.category:category	example	ValueSetCompositionCategoryMyCore (a valid code from CodeSystemCompositionCategory (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-core from this IG
Composition.category:class	example	ValueSetCompositionClassMyCore (a valid code from CodeSystemCompositionClass (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-core from this IG
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.event.code	extensible	ValueSetCompositionEventMyCore (a valid code from CodeSystemCompositionEvent (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-event-my-core from this IG
Composition.section.code	example	ValueSetCompositionSectionMyCore http://fhir.hie.moh.gov.my/ValueSet/composition-section-my-core from this IG
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

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

This structure is derived from Composition

Summary

Mandatory: 6 elements
Fixed: 2 elements

Extensions

This structure refers to these extensions:

• http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
• http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from Composition

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
Slices for extension				Content/Rules for all slices
locationRecorded		0..1	Reference(Location) {r}	An extension to define where the Composition was recorded (Location Resource) URL: http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
type		1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: ValueSetCompositionType (MY Core) (extensible)
Slices for category		1..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system
category:category		0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionCategory (MY Core) (example)
coding
system		0..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core
category:class		0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example)
coding
system		0..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-class-my-core
subject		1..1	Reference(Patient)	Who and/or what the composition is about
confidentiality		0..1	code	As defined by affinity domain Binding: V3 Value SetConfidentialityClassification (required)
custodian		1..1	Reference(Organization)	Organization which maintains the composition
event		1..*	BackboneElement	The clinical service(s) being documented
code		0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: ValueSetCompositionEvent (MY Core) (extensible)
section		1..*	BackboneElement	Composition is broken into sections
Slices for extension				Content/Rules for all slices
sectionDate		0..1	dateTime	Extension to define the date this section was created on URL: http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core
code		1..1	CodeableConcept	Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.type	extensible	ValueSetCompositionTypeMyCore (a valid code from CodeSystemCompositionType (MY Core)) http://fhir.hie.moh.gov.my/ValueSet/composition-type-my-core from this IG
Composition.category:category	example	ValueSetCompositionCategoryMyCore (a valid code from CodeSystemCompositionCategory (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-core from this IG
Composition.category:class	example	ValueSetCompositionClassMyCore (a valid code from CodeSystemCompositionClass (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-core from this IG
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.event.code	extensible	ValueSetCompositionEventMyCore (a valid code from CodeSystemCompositionEvent (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-event-my-core from this IG
Composition.section.code	example	ValueSetCompositionSectionMyCore http://fhir.hie.moh.gov.my/ValueSet/composition-section-my-core from this IG

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension				Content/Rules for all slices
locationRecorded		0..1	Reference(Location) {r}	An extension to define where the Composition was recorded (Location Resource) URL: http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
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	Kind of composition (LOINC if possible) Binding: ValueSetCompositionType (MY Core) (extensible)
Slices for category	Σ	1..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:category	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionCategory (MY Core) (example)
category:class	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example)
subject	Σ	1..1	Reference(Patient)	Who and/or what the composition is about
date	Σ	1..1	dateTime	Composition editing time
author	Σ	1..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the composition
title	Σ	1..1	string	Human Readable name/title
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: V3 Value SetConfidentialityClassification (required)
custodian	Σ	1..1	Reference(Organization)	Organization which maintains the composition
event	Σ	1..*	BackboneElement	The clinical 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 event being documented Binding: ValueSetCompositionEvent (MY Core) (extensible)
section	C	1..*	BackboneElement	Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
Slices for extension				Content/Rules for all slices
sectionDate		0..1	dateTime	Extension to define the date this section was created on URL: http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	ValueSetCompositionTypeMyCore (a valid code from CodeSystemCompositionType (MY Core)) http://fhir.hie.moh.gov.my/ValueSet/composition-type-my-core from this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.category:category	example	ValueSetCompositionCategoryMyCore (a valid code from CodeSystemCompositionCategory (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-core from this IG
Composition.category:class	example	ValueSetCompositionClassMyCore (a valid code from CodeSystemCompositionClass (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-core from this IG
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.event.code	extensible	ValueSetCompositionEventMyCore (a valid code from CodeSystemCompositionEvent (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-event-my-core from this IG
Composition.section.code	example	ValueSetCompositionSectionMyCore http://fhir.hie.moh.gov.my/ValueSet/composition-section-my-core from this IG

Constraints

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

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
locationRecorded		0..1	Reference(Location) {r}	An extension to define where the Composition was recorded (Location Resource) URL: http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Version-independent identifier for the Composition
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	Kind of composition (LOINC if possible) Binding: ValueSetCompositionType (MY Core) (extensible)
Slices for category	Σ	1..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:category	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionCategory (MY Core) (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category:class	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-class-my-core
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subject	Σ	1..1	Reference(Patient)	Who and/or what the composition is about
encounter	Σ	0..1	Reference(Encounter)	Context of the Composition
date	Σ	1..1	dateTime	Composition editing time
author	Σ	1..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the composition
title	Σ	1..1	string	Human Readable name/title
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: V3 Value SetConfidentialityClassification (required)
attester		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.
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)	Who attested the composition
custodian	Σ	1..1	Reference(Organization)	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	1..*	BackboneElement	The clinical service(s) being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: ValueSetCompositionEvent (MY Core) (extensible)
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
section	C	1..*	BackboneElement	Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
sectionDate		0..1	dateTime	Extension to define the date this section was created on URL: http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example)
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
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	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	ValueSetCompositionTypeMyCore (a valid code from CodeSystemCompositionType (MY Core)) http://fhir.hie.moh.gov.my/ValueSet/composition-type-my-core from this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.category:category	example	ValueSetCompositionCategoryMyCore (a valid code from CodeSystemCompositionCategory (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-core from this IG
Composition.category:class	example	ValueSetCompositionClassMyCore (a valid code from CodeSystemCompositionClass (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-core from this IG
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.event.code	extensible	ValueSetCompositionEventMyCore (a valid code from CodeSystemCompositionEvent (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-event-my-core from this IG
Composition.section.code	example	ValueSetCompositionSectionMyCore http://fhir.hie.moh.gov.my/ValueSet/composition-section-my-core from this IG
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

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

This structure is derived from Composition

Summary

Mandatory: 6 elements
Fixed: 2 elements

Extensions

This structure refers to these extensions:

• http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
• http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core

Slices

This structure defines the following Slices:

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

Other representations of profile: CSV, Excel, Schematron