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.
6.8.1
Scope
and
Usage
A
Composition
is
also
the
basic
structure
from
which
FHIR
Documents
-
immutable
bundles
with
attested
narrative
-
are
built.
A
single
logical
composition
may
be
associated
with
a
series
of
derived
documents,
each
of
which
is
a
frozen
copy
of
the
composition.
Note:
EN
13606
uses
the
term
"Composition"
to
refer
to
a
single
commit
to
an
EHR
system,
and
offers
some
common
examples:
a
consultation
note,
a
progress
note,
a
report
or
a
letter,
an
investigation
report,
a
prescription
form
and
a
set
of
bedside
nursing
observations.
These
logical
examples
are
all
valid
uses
of
a
Composition
resource,
but
it
is
not
required
that
all
the
resources
are
updated
in
a
single
commit.
6.8.2
Background
and
Context
6.8.2.1
Composition
Status
Codes
Every
composition
has
a
status,
which
describes
the
status
of
the
content
of
the
composition,
taken
from
this
list
of
codes:
Code
Definition
preliminary
This
is
a
preliminary
composition
(also
known
as
initial
or
interim).
The
content
may
be
incomplete
or
unverified.
final
The
composition
is
complete
and
verified
by
an
appropriate
person
and
no
further
work
is
planned
appended
The
composition
has
been
modified
subsequent
to
being
marked
and/or
released
as
"final"
and
is
complete
and
verified
by
an
authorized
person.
The
modifications
added
new
information
to
the
composition,
but
did
not
revise
existing
content
amended
The
composition
content
or
the
referenced
resources
have
been
modified
subsequent
to
being
released
as
"final"
and
the
composition
is
complete
and
verified
by
an
authorized
person
retracted
The
composition
was
originally
created/issued
in
error
and
this
is
an
amendment
that
marks
that
the
entire
composition
and
any
past
versions
or
copies
should
not
be
considered
as
valid
Composition
status
generally
only
moves
down
through
this
list
-
it
moves
from
preliminary
to
final
and
then
it
may
progress
to
either
appended
or
amended.
Note
that
in
many
workflows,
only
final
compositions
are
made
available
and
the
preliminary
status
is
not
used.
A
very
few
compositions
are
created
entirely
in
error
in
the
workflow
-
usually
the
composition
concerns
the
wrong
patient
or
is
written
by
the
wrong
author,
and
the
error
is
only
detected
after
the
composition
has
been
used
or
documents
have
been
derived
from
it.
To
support
resolution
of
this
case,
the
composition
is
updated
to
be
marked
as
"retracted"
and
a
new
derived
document
can
be
created.
This
means
that
the
entire
series
of
derived
documents
is
now
considered
to
be
created
in
error
and
systems
receiving
derived
documents
based
on
retracted
compositions
SHOULD
remove
data
taken
from
earlier
documents
from
routine
use
and/or
take
other
appropriate
actions.
Systems
are
not
required
to
provide
this
workflow
or
support
documents
derived
from
retracted
compositions,
but
they
SHALL
not
ignore
a
status
of
retracted.
Note
that
systems
that
handle
compositions
or
derived
documents
and
don't
support
the
retracted
status
need
to
define
some
other
way
of
handling
compositions
that
are
created
in
error;
while
this
is
not
a
common
occurrence,
some
clinical
systems
have
no
provision
for
removing
erroneous
information
from
a
patient's
record
and
there
is
no
way
for
a
user
to
know
that
it
is
not
fit
for
use
-
this
is
not
safe.
Inv-2
:
On
Composition.section:
A
section
SHALL
have
content
or
one
or
more
sections,
but
not
both.
(xpath
on
f:Composition/f:section:
exists(f:content)
!=
exists(f:section)
)
6.8.4
Notes:
The
author
and
the
attester
are
often
the
same
person,
but
this
may
not
be
the
case
in
some
clinical
workflows
The
attester
attests
contents
of
the
document
resource,
the
subject
resource
and
the
resources
referred
to
in
the
Composition.section.content
references.
Because
documents
are
often
derived
Compositions
and
the
attestation
from
the
composition
is
held
to
apply
to
the
document,
the
method
for
presenting
a
document
should
be
used
when/if
attesters
review
the
content
of
the
composition
The
custodian
is
responsible
for
the
maintenance
of
the
composition
and
any
documents
derived
from
it.
With
regard
to
the
documents,
they
are
responsible
for
the
policy
regarding
persistence
of
the
documents.
Although
they
need
not
actually
retain
a
copy
of
the
document,
they
SHOULD
do
so.
Narrative
only
sections
can
be
created
by
setting
Content
to
a
resource
of
the
appropriate
type
and
only
populating
the
narrative
portion
of
the
resource.
If
the
meaning
of
the
section
is
such
that
an
appropriate
resource
does
not
exist,
the
Other
resource
should
be
used.
(In
some
cases,
the
a
resource
may
have
mandatory
elements
that
preclude
the
resource
containing
only
narrative.
This
will
be
addressed
in
a
future
release,
but
for
now,
Other
should
be
used
in
these
circumstances
as
well.)
6.8.5
Search
Parameters
Search
parameters
for
this
resource.
The
standard
parameters
also
apply.
See
Searching
for
more
information
about
searching
in
REST,
messaging,
and
services.
.
Page
versions:
R5
R4B
R4
R3
R2
<!-- from Resource: extension, modifierExtension, language, text, and contained --> <identifier><!-- 0..1 Identifier Logical identifier of composition (version-independent) § --></identifier> <date value="[dateTime]"/><!-- 1..1 Composition editing time § --> <type><!-- 1..1 CodeableConcept Kind of composition (LOINC if possible) § --></type> <class><!-- 0..1 CodeableConcept Categorization of Composition § --></class> <title value="[string]"/><!-- 0..1 Human Readable name/title § --> <status value="[code]"/><!-- 1..1 preliminary | final | appended | amended | entered in error § --> <confidentiality><!-- 1..1 Coding As defined by affinity domain § --></confidentiality> <subject><!-- 1..1 Resource(Patient|Practitioner|Group|Device|Location) Who and/or what the composition is about § --></subject> <author><!-- 1..* Resource(Practitioner|Device|Patient|RelatedPerson) Who and/or what authored the composition § --></author> <attester> <!-- 0..* Attests to accuracy of composition § --> <mode value="[code]"/><!-- 1..* personal | professional | legal | official § --> <time value="[dateTime]"/><!-- 0..1 When composition attested § --> <party><!-- 0..1 Resource(Patient|Practitioner|Organization) Who attested the composition § --></party> </attester> <custodian><!-- 0..1 Resource(Organization) Org which maintains the composition § --></custodian> <event> <!-- 0..1 The clinical event/act/item being documented § --> <code><!-- 0..* CodeableConcept Code(s) that apply to the event being documented § --></code> <period><!-- 0..1 Period The period covered by the documentation § --></period> <detail><!-- 0..* Resource(Any) Full details for the event(s) the composition consents § --></detail> </event> <encounter><!-- 0..1 Resource(Encounter) Context of the conposition § --></encounter> <section> <!-- 0..* Composition is broken into sections --> <title value="[string]"/><!-- 0..1 Label for section --> <code><!-- 0..1 CodeableConcept Classification of section (recommended) --></code> <subject><!-- 0..1 Resource(Patient|Group|Device) If section different to composition --></subject> <content><!--
0..1 Resource(Any) The actual data for the section --></content> <section><!--
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