Example
Provenance/example-delete
(Narrative)
StructureDefinition:
ClinicalDocument
ClinicalDocument
This
is
the
narrative
for
the
resource.
See
also
the
XML
,
JSON
or
Turtle
format.
This
example
conforms
to
the
profile
Provenance
.
Raw
XML
Generated
Narrative:
Provenance
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
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 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.
To support documents, and also to capture the EN13606 notion of an attested commit to
the patient EHR, and to allow a set of disparate resources at the information/engineering
level to be gathered into a clinical statement.
The logical id of the resource, as used in the url for the resoure. Once assigned, this
value never changes.
The only time that a resource does not have an id is when it is being submitted to the
server using a create operation. Bundles always have an id, though it is usually a generated
UUID.
The metadata about the resource. This is content that is maintained by the infrastructure.
Changes to the content may not always be associated with version changes to the resource.
A reference to a set of rules that were followed when the resource was constructed, and
which must be understood when processing the content.
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 as much as possible.
Language is provided to support indexing and accessibility (typically, services such as
text to speech use the language tag). The html language tag in the narrative applies
to the narrative. The language tag on the resource may be used to specify the language
of other presentations generated from the data in the resource Not all the content has
to be in the base language. The Resource.language should not be assumed to apply to the
narrative automatically. If a language is specified, it should it also be specified on
the div element in the html (see rules in HTML5 for information about the relationship
between xml:lang and the html lang attribute).
A human-readable narrative that contains a summary of the resource, and may 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.
These resources do not have an independent existence apart from the resource that contains
them - they cannot be identified independently, and nor can they have their own independent
transaction scope.
This should never be done when the content can be identified properly, as once identification
is lost, it is extremely difficult (and context dependent) to restore it again.
May be used to represent additional information that is not part of the basic definition
of the resource. In order 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.
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.
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.
Usually modifier elements provide negation or qualification. In order 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.
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.
Logical Identifier for the composition, assigned when created. This identifier stays constant
as the composition is changed over time.
The Last Modified Date on the composition may be after the date of the document was attested
without being changed.
Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary,
Progress Note). This usually equates to the purpose of making the composition.
A categorization for the type of the composition. This may be implied by or derived from
the code specified in the Composition Type.
Helps humans to assess whether the composition is of interest when viewing an index of
compositions or documents.
.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN&quo
t;].code
If compositions do not have a title, the text or a display name of Composition.type (e.g.
a "consultation" or "progress note") can be used in its place.
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 "withdrawn" is why this element
is labeled as a modifier of other elements.
interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active";
final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete&q
uot; and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[su
bsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseCompo
sition", code) and isNormalAct()]); amended: .completionCode="AU" &&
./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ
" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and
moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()
and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNo
rmalDatatype()]="obsolete"
The exact use of this element, and enforcement and issues related to highly sensitive
documents are out of scope for the base specification, and delegated to implementation
profiles (see security section).
Who or what the composition is about. The composition can be about a person, (patient
or healthcare practitioner), a device (I.e. 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).
Essential metadata for searching for the composition. Identifies who and/or what the composition/doc
ument is about.
Identifies who is responsible for the information in the composition. (Not necessarily
who typed it in.).
May be used to represent additional information that is not part of the basic definition
of the element. In order 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.
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.
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 that contains it. Usually
modifier elements provide negation or qualification. In order 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.
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.
Use more than one code where a single attester has more than one mode (professional and
legal are often paired).
Identifies when the information in the composition was deemed accurate. (Things may have
changed since then.).
./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST"
and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASS
IGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and
classCode="ORG" and isNormalEntity()]
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 knowing this is sometimes
not known by the authoring system, and can be inferred by context. However it's important
that this information be known when working with a derived document, so providing a custodian
is encouraged.
.participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG
" and determinerCode="INST"]
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. In order 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.
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.
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 that contains it. Usually
modifier elements provide negation or qualification. In order 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.
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.
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.
The period of time covered by the documentation. There is no assertion that the documentation
is a complete representation for this period, only that it documents events during this
time.
unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()],
priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR")
and isNormalAct])
./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode=&quo
t;EVN" and classCode="DOCSECT" and isNormalAct]
May be used to represent additional information that is not part of the basic definition
of the element. In order 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.
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.
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 that contains it. Usually
modifier elements provide negation or qualification. In order 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.
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.
The label for this particular section. This will be part of the rendered content for
the document, and is often used to build a table of contents.
The title identifies the section for a human reader. The title must be consistent with
the narrative of the resource that is the target of the section.content reference.
Section headings are often standardized for different types of documents. They give guidance
to humans on how the document is organized.
A code identifying the kind of content contained within the section. This must be consistent
with the section title.
The code identifies the section for an automated processor of the document. This is particularly
relevant when using profiles to control the structure of the document. If the section
has content (instead of sub-sections), the section.code does not change the meaning or
interpretation of the resource that is the content of the section in the comments for
the section.code.
Because composition represent point-in-time snapshots, resource references should either
be to a specific version, or made against resources on the same server with full version
tracking, so that the correct versions can easily be assembled.
unique(./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCo
de="EVN" and classCode!="DOCSECT" and isNormalAct])
Nested sections are primarily used to help human readers navigate to particular portions
of the document.
./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode=&quo
t;EVN" and classCode="DOCSECT" and isNormalAct]
Resource
Provenance
"example-delete"
target
:
http://terminology.hl7.org/CodeSystem/location-physical-type/_history/3
recorded
:
27
June
2015,
8:39:24
am
Authorizations
|
-
|
Concept
</StructureDefinition>
|
|
*
|
metadata
management
(
ActReason
#METAMGT)
|
activity
:
delete
(
DataOperation
#DELETE)
Agents
Entities
Usage
note:
every
effort
has
been
made
to
ensure
that
the
examples
are
correct
and
useful,
but
they
are
not
a
normative
part
of
the
specification.
Security
and
Privacy
|
Propose
a
change