DSTU2 STU 3 Candidate
This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . For a full list of available versions, see the Directory of published versions . Page versions: . Page versions: R5 R4B R4 R3 R2

6.8.13.2 6.9.12.2 StructureDefinition: ClinicalDocument StructureDefinition: ClinicalDocument The official URL for this profile is:

The official URL for this profile is:

http://hl7.org/fhir/StructureDefinition/clinicaldocument
The
base
Composition
is
a
general
resource
for
compositions
or
documents
about
any
kind
of
subject
that
might
be
encountered
in
healthcare
including
such
things
as
guidelines,
medicines,
etc.
A
clinical
document
is
focused
on
documents
related
to
the
provision
of
care
process,
where
the
subject
is
a
patient,
a
group
of
patients,
or
a
closely
related
concept.
A
clinical
document
has
additional
reqiurements
around
confidentiality
that
do
not
apply
in
the
same
way
to
other
kinds
of
documents
This
profile
was
published
on
Tue,
Mar
17,
2015
00:00+1100
as
a
draft
by
Health
Level
Seven,
Inc.
-
Structured
Documents
WG.

The base Composition is a general resource for compositions or documents about any kind of subject that might be encountered in healthcare including such things as guidelines, medicines, etc. A clinical document is focused on documents related to the provision of care process, where the subject is a patient, a group of patients, or a closely related concept. A clinical document has additional reqiurements around confidentiality that do not apply in the same way to other kinds of documents

This profile was published on Tue, Mar 17, 2015 00:00+1100 as a draft by Health Level Seven, Inc. - Structured Documents WG.

6.8.13.2.1 Formal Views of Profile Content 6.9.12.2.1 Formal Views of Profile Content Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work .

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

This structure is derived from Composition .

Summary Summary This structure is derived from

Name Flags Card. Type Description & Constraints Description & Constraints doco
. . Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation A set of resources composed into a single coherent clinical statement with clinical attestation
. . . meta 0..1 Meta Metadata about the resource Metadata about the resource
. . . implicitRules ?! ?! 0..1 uri A set of rules under which this content was created A set of rules under which this content was created
. . . language 0..1 code Language of the resource content Language of the resource content
Binding: Binding: IETF BCP-47 IETF BCP-47 ( ( required )
. . . text I 0..1 Narrative Text summary of the resource, for human interpretation Text summary of the resource, for human interpretation
. . . contained 0..* Resource Contained, inline Resources Contained, inline Resources
. . . extension 0..* Extension Additional Content defined by implementations Additional Content defined by implementations
. . . modifierExtension ?! 0..* Extension Extensions that cannot be ignored Extensions that cannot be ignored
. . . identifier 0..1 Identifier Logical identifier of composition (version-independent) Logical identifier of composition (version-independent)
. . . date 1..1 dateTime Composition editing time Composition editing time
. . . type 1..1 CodeableConcept Kind of composition (LOINC if possible) Kind of composition (LOINC if possible)
Binding: Binding: FHIR Document Type Codes ( FHIR Document Type Codes ( preferred )
. . . class 0..1 CodeableConcept Categorization of Composition Categorization of Composition
Binding: Binding: FHIR Document Class Codes ( FHIR Document Class Codes ( example )
. . . title 1..1 string Human Readable name/title Human Readable name/title
. . . status ?! ?! 1..1 code preliminary | final | amended | entered-in-error preliminary | final | amended | entered-in-error
Binding: Binding: CompositionStatus ( ( required )
. . . confidentiality ?! ?! 0..1 code As defined by affinity domain As defined by affinity domain
Binding: Binding: v3 Code System Confidentiality ( v3 Code System Confidentiality ( required )
. . . subject 1..1 Reference ( Patient | | Practitioner | | Group | | Device | | Location ) Who and/or what the composition is about Who and/or what the composition is about
. . . author 1..* Reference ( Practitioner | | Device | | Patient | | RelatedPerson ) Who and/or what authored the composition Who and/or what authored the composition
. . . attester 0..* BackboneElement Attests to accuracy of composition Attests to accuracy of composition
. . . . extension 0..* Extension Additional Content defined by implementations Additional Content defined by implementations
. . . . modifierExtension ?! ?! 0..* Extension Extensions that cannot be ignored Extensions that cannot be ignored
. . . . mode 1..* code personal | professional | legal | official personal | professional | legal | official
Binding: Binding: CompositionAttestationMode ( ( required )
. . . . time 0..1 dateTime When composition attested When composition attested
. . . . party 0..1 Reference ( Patient | | Practitioner | | Organization ) Who attested the composition Who attested the composition
. . . custodian 0..1 Reference ( Organization ) Organization which maintains the composition Organization which maintains the composition
. . . event 0..* BackboneElement The clinical service(s) being documented The clinical service(s) being documented
. . . . extension 0..* Extension Additional Content defined by implementations Additional Content defined by implementations
. . . . modifierExtension ?! ?! 0..* Extension Extensions that cannot be ignored Extensions that cannot be ignored
. . . . code 0..* CodeableConcept Code(s) that apply to the event being documented Code(s) that apply to the event being documented
Binding: Binding: v3 Code System ActCode ( v3 Code System ActCode ( example )
. . . . period 0..1 Period The period covered by the documentation The period covered by the documentation
. . . . detail 0..* Reference ( Resource ) The event(s) being documented The event(s) being documented
. . . encounter 0..1 Reference ( Encounter ) Context of the Composition Context of the Composition
. . . section I 0..* BackboneElement Composition is broken into sections Composition is broken into sections
cmp-2: A section can only have an emptyReason if it is empty cmp-2: A section can only have an emptyReason if it is empty
cmp-1: A section must at least one of text, entries, or sub-sections cmp-1: A section must at least one of text, entries, or sub-sections
. . . . extension 0..* Extension Additional Content defined by implementations Additional Content defined by implementations
. . . . modifierExtension ?! ?! 0..* Extension Extensions that cannot be ignored Extensions that cannot be ignored
. . . . title 0..1 string Label for section (e.g. for ToC) Label for section (e.g. for ToC)
. . . . code 0..1 CodeableConcept Classification of section (recommended) Classification of section (recommended)
Binding: Binding: Document Section Codes ( Document Section Codes ( example )
. . . . text I 0..1 Narrative Text summary of the section, for human interpretation Text summary of the section, for human interpretation
. . . . mode ?! ?! 0..1 code working | snapshot | changes working | snapshot | changes
Binding: Binding: ListMode ( ( required )
. . . . orderedBy 0..1 CodeableConcept Order of section entries Order of section entries
Binding: Binding: List Order Codes ( List Order Codes ( preferred )
. . . . entry I 0..* Reference ( Resource ) A reference to data that supports this section A reference to data that supports this section
. . . . emptyReason I 0..1 CodeableConcept Why the section is empty Why the section is empty
Binding: Binding: List Empty Reasons ( List Empty Reasons ( preferred )
. . . . section I 0..* Nested Section Unknown reference to #section
Nested Section

Documentation for this format doco Documentation for this format

todo This structure is derived from

This structure is derived from Composition .

Summary Summary

Snapshot View Snapshot View

Name Flags Card. Type Description & Constraints Description & Constraints doco
. . Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation A set of resources composed into a single coherent clinical statement with clinical attestation
. . . meta 0..1 Meta Metadata about the resource Metadata about the resource
. . . implicitRules ?! ?! 0..1 uri A set of rules under which this content was created A set of rules under which this content was created
. . . language 0..1 code Language of the resource content Language of the resource content
Binding: Binding: IETF BCP-47 IETF BCP-47 ( ( required )
. . . text I 0..1 Narrative Text summary of the resource, for human interpretation Text summary of the resource, for human interpretation
. . . contained 0..* Resource Contained, inline Resources Contained, inline Resources
. . . extension 0..* Extension Additional Content defined by implementations Additional Content defined by implementations
. . . modifierExtension ?! 0..* Extension Extensions that cannot be ignored Extensions that cannot be ignored
. . . identifier 0..1 Identifier Logical identifier of composition (version-independent) Logical identifier of composition (version-independent)
. . . date 1..1 dateTime Composition editing time Composition editing time
. . . type 1..1 CodeableConcept Kind of composition (LOINC if possible) Kind of composition (LOINC if possible)
Binding: Binding: FHIR Document Type Codes ( FHIR Document Type Codes ( preferred )
. . . class 0..1 CodeableConcept Categorization of Composition Categorization of Composition
Binding: Binding: FHIR Document Class Codes ( FHIR Document Class Codes ( example )
. . . title 1..1 string Human Readable name/title Human Readable name/title
. . . status ?! ?! 1..1 code preliminary | final | amended | entered-in-error preliminary | final | amended | entered-in-error
Binding: Binding: CompositionStatus ( ( required )
. . . confidentiality ?! ?! 0..1 code As defined by affinity domain As defined by affinity domain
Binding: Binding: v3 Code System Confidentiality ( v3 Code System Confidentiality ( required )
. . . subject 1..1 Reference ( Patient | | Practitioner | | Group | | Device | | Location ) Who and/or what the composition is about Who and/or what the composition is about
. . . author 1..* Reference ( Practitioner | | Device | | Patient | | RelatedPerson ) Who and/or what authored the composition Who and/or what authored the composition
. . . attester 0..* BackboneElement Attests to accuracy of composition Attests to accuracy of composition
. . . . extension 0..* Extension Additional Content defined by implementations Additional Content defined by implementations
. . . . modifierExtension ?! ?! 0..* Extension Extensions that cannot be ignored Extensions that cannot be ignored
. . . . mode 1..* code personal | professional | legal | official personal | professional | legal | official
Binding: Binding: CompositionAttestationMode ( ( required )
. . . . time 0..1 dateTime When composition attested When composition attested
. . . . party 0..1 Reference ( Patient | | Practitioner | | Organization ) Who attested the composition Who attested the composition
. . . custodian 0..1 Reference ( Organization ) Organization which maintains the composition Organization which maintains the composition
. . . event 0..* BackboneElement The clinical service(s) being documented The clinical service(s) being documented
. . . . extension 0..* Extension Additional Content defined by implementations Additional Content defined by implementations
. . . . modifierExtension ?! ?! 0..* Extension Extensions that cannot be ignored Extensions that cannot be ignored
. . . . code 0..* CodeableConcept Code(s) that apply to the event being documented Code(s) that apply to the event being documented
Binding: Binding: v3 Code System ActCode ( v3 Code System ActCode ( example )
. . . . period 0..1 Period The period covered by the documentation The period covered by the documentation
. . . . detail 0..* Reference ( Resource ) The event(s) being documented The event(s) being documented
. . . encounter 0..1 Reference ( Encounter ) Context of the Composition Context of the Composition
. . . section I 0..* BackboneElement Composition is broken into sections Composition is broken into sections
cmp-2: A section can only have an emptyReason if it is empty cmp-2: A section can only have an emptyReason if it is empty
cmp-1: A section must at least one of text, entries, or sub-sections cmp-1: A section must at least one of text, entries, or sub-sections
. . . . extension 0..* Extension Additional Content defined by implementations Additional Content defined by implementations
. . . . modifierExtension ?! ?! 0..* Extension Extensions that cannot be ignored Extensions that cannot be ignored
. . . . title 0..1 string Label for section (e.g. for ToC) Label for section (e.g. for ToC)
. . . . code 0..1 CodeableConcept Classification of section (recommended) Classification of section (recommended)
Binding: Binding: Document Section Codes ( Document Section Codes ( example )
. . . . text I 0..1 Narrative Text summary of the section, for human interpretation Text summary of the section, for human interpretation
. . . . mode ?! ?! 0..1 code working | snapshot | changes working | snapshot | changes
Binding: Binding: ListMode ( ( required )
. . . . orderedBy 0..1 CodeableConcept Order of section entries Order of section entries
Binding: Binding: List Order Codes ( List Order Codes ( preferred )
. . . . entry I 0..* Reference ( Resource ) A reference to data that supports this section A reference to data that supports this section
. . . . emptyReason I 0..1 CodeableConcept Why the section is empty Why the section is empty
Binding: Binding: List Empty Reasons ( List Empty Reasons ( preferred )
. . . . section I 0..* Nested Section Unknown reference to #section
Nested Section

Documentation for this format doco Documentation for this format

XML Template XML Template

JSON Template JSON Template

todo

  Other representations of profile:

Other representations of profile: Schematron

6.8.13.2.2 Terminology Bindings 6.9.12.2.2 Terminology Bindings

Path Name Conformance ValueSet
Composition.language ?ext required http://tools.ietf.org/html/bcp47 http://tools.ietf.org/html/bcp47
Composition.type FHIR Document Type Codes FHIR Document Type Codes preferred FHIR Document Type Codes FHIR Document Type Codes
Composition.class FHIR Document Class Codes FHIR Document Class Codes example FHIR Document Class Codes FHIR Document Class Codes
Composition.status CompositionStatus required CompositionStatus
Composition.confidentiality v3 Code System Confidentiality v3 Code System Confidentiality required v3 Code System Confidentiality v3 Code System Confidentiality
Composition.attester.mode CompositionAttestationMode required CompositionAttestationMode
Composition.event.code v3 Code System ActCode v3 Code System ActCode example v3 Code System ActCode v3 Code System ActCode
Composition.section.code Document Section Codes Document Section Codes example Document Section Codes Document Section Codes
Composition.section.mode ListMode required ListMode
Composition.section.orderedBy List Order Codes List Order Codes preferred List Order Codes List Order Codes
Composition.section.emptyReason List Empty Reasons List Empty Reasons preferred List Empty Reasons List Empty Reasons

6.8.13.2.3 6.9.12.2.3 Constraints Constraints

Id Path Details Requirements
cmp-2 Composition.section A section can only have an emptyReason if it is empty A section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry)) XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1 Composition.section A section must at least one of text, entries, or sub-sections A section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section) XPath: exists(f:text) or exists(f:entry) or exists(f:section)
. © HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100. Links: Search
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