Release 4B 5

This page is part of the FHIR Specification (v4.3.0: R4B (v5.0.0: R5 - STU ). The This is the current published version which supercedes in it's permanent home (it will always be available at this version is 5.0.0 . URL). For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R5 R4B R4 R3 R2

Structured Documents icon Work Group   Maturity Level : 0 Trial Use Use Context : Any

The official canonical URL for this profile is:

http://hl7.org/fhir/StructureDefinition/clinicaldocument

The Clinical Document profile constrains Composition to specify a clinical document (matching CDA). 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 requirements 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 Thu, Jan 1, 1970 00:00+1000 as a draft by Health Level Seven, Inc. - Structured Documents WG. HL7.

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

This structure is derived from Composition .

Summary

Extensions This structure refers to these extensions: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber

This structure is derived from indicates the differences between this profile and the base Composition . structure.

composition-clinicaldocument-versionNumber 0 .. 1 string Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
Name Flags Card. Type Description & Constraints doco
. . Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
. . . subject 0 .. 1 * Reference ( Patient | Practitioner | Group | Device | Location ) Who and/or what the composition is about

doco Documentation for this format icon

This provides the consolidated view (aka snapshot) of the profile after applying the changes in this profile to the base Composition structure.

All Languages Max Binding 0..1 Binding: Confidentiality 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 ) mode 0..1 code working | snapshot | changes Binding: ListMode ( required ): The processing mode that applies to this section. I
Name Flags Card. Type Description & Constraints doco
. . 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: Common All Languages ( preferred required ): IETF language tag for a human language

Additional Bindings Purpose
. . . 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 Additional content defined by value:url implementations
. . composition-clinicaldocument-versionNumber . modifierExtension ?! Σ 0..1 0..* string Extension Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber Extensions that cannot be ignored
. . modifierExtension . url ?! Σ 0..* 0..1 Extension uri Extensions that cannot be ignored Canonical identifier for this Composition, represented as a URI (globally unique)
. . . identifier Σ 0..1 0..* Identifier Version-independent identifier for the Composition
. . . version Σ 0..1 string An explicitly assigned identifer of a variation of the content in the Composition
... status ?! Σ 1..1 code registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
Binding: CompositionStatus Composition Status ( required ): The workflow/clinical status of the composition.

. . . type Σ 1..1 CodeableConcept Kind of composition (LOINC if possible)
Binding: FHIR Document Type Codes ( preferred ): Type of a composition.

. . . category Σ 0..* CodeableConcept Categorization of Composition
Binding: LoincDocumentOntologyInternational Referenced Item Category Value Set ( example ): High-level kind of a clinical document at a macro level.


. . . subject Σ 0..* Reference ( Patient | Practitioner | Group | Device | Location ) 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
. . . useContext Σ 0..* UsageContext The context that the content is intended to support
. . . author Σ 1..* Reference ( Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization ) Who and/or what authored the composition
. . . title name Σ 1..1 0..1 string Human Readable name/title Name for this Composition (computer friendly)
. . . confidentiality title Σ 0..1 1..1 code string As defined by affinity domain Human Readable name/title
. . . note ( required ): Codes specifying the level of confidentiality of the composition. 0..* Annotation For any additional notes
. . . 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 CodeableConcept personal | professional | legal | official
Binding: CompositionAttestationMode Composition Attestation Mode ( required preferred ): 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 0..1 Reference ( Organization ) Organization which maintains the composition
. . . relatesTo 0..* BackboneElement RelatedArtifact Relationships to other compositions/documents
. . . event Σ 0..* 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: v3 Code System ActCode ( example ): This list of codes represents the main clinical acts being documented. period Σ 0..1 Period The period covered by the documentation
. . . . detail Σ 0..* Reference CodeableReference ( Resource ) The event(s) being documented documented, as code(s), reference(s), or both
Binding: v3 Code System ActCode icon ( example ): This list of codes represents the main clinical acts being documented.


. . . section I C icon 0..* BackboneElement Composition is broken into sections
. . . . 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
. . . . title 0..1 string Label for section (e.g. for ToC)
. . . . code 0..1 CodeableConcept Classification of section (recommended)
Binding: Document Section Codes ( example ): Classification of a section of a composition/document.

. . . . 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 I C icon 0..1 Narrative Text summary of the section, for human interpretation
. . . . orderedBy 0..1 CodeableConcept Order of section entries
Binding: List Order Codes ( preferred ): What order applies to the items in the entry.

. . . . entry I C icon 0..* Reference ( Resource ) A reference to data that supports this section
. . . . emptyReason I C icon 0..1 CodeableConcept Why the section is empty
Binding: List Empty Reasons ( preferred ): If a section is empty, why it is empty.

. . . . section 0..* See section (Composition) Nested Section

doco Documentation for this format icon
<!-- Clinical Document -->

<!-- ClinicalDocument -->doco


<Composition xmlns="http://hl7.org/fhir"
>
  <!-- from Element: extension -->
 <id value="[id]"/><!-- 0..1 Logical id of this artifact -->
 <</meta>
 <
 <
 <

 <meta><!-- I 0..1 Meta Metadata about the resource --></meta>
 <implicitRules value="[uri]"/><!-- I 0..1 A set of rules under which this content was created -->
 <language value="[code]"/><!-- I 0..1 Language of the resource content   -->
 <text><!-- I 0..1 Narrative 

     Text summary of the resource, for human interpretation --></text>
 <</contained>
 <<a href="clinicaldocument-definitions.html#Composition.modifierExtension" title="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.

 <contained><!-- 0..* Resource Contained, inline Resources --></contained>
 <Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict"></modifierExtension>
 <

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict">modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
 <url value="[uri]"/><!-- I 0..1 Canonical identifier for this Composition, represented as a URI (globally unique) -->
 <identifier><!-- I 0..* Identifier 

     Version-independent identifier for the Composition --></identifier>
 <
 <</type>
 <</category>
 <

 <version value="[string]"/><!-- I 0..1 
     An explicitly assigned identifer of a variation of the content in the Composition -->
 <status value="[code]"/><!-- I 1..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown   -->
 <type><!-- I 1..1 CodeableConcept Kind of composition (LOINC if possible)   --></type>
 <category><!-- I 0..* CodeableConcept Categorization of Composition   --></category>
 <subject><!-- I 0..* Reference(Patient) 

     Who and/or what the composition is about --></subject>
 <</encounter>
 <
 <

 <encounter><!-- I 0..1 Reference(Encounter) Context of the Composition --></encounter>
 <date value="[dateTime]"/><!-- I 1..1 Composition editing time -->
 <useContext><!-- I 0..* UsageContext 
     The context that the content is intended to support --></useContext>
 <author><!-- I 1..* Reference(Practitioner) 

     Who and/or what authored the composition --></author>
 <
 <
 <
  <<a href="clinicaldocument-definitions.html#Composition.attester.modifierExtension" title="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.

 <name value="[string]"/><!-- I 0..1 Name for this Composition (computer friendly) -->
 <title value="[string]"/><!-- I 1..1 Human Readable name/title -->
 <note><!-- I 0..* Annotation For any additional notes --></note>
 <attester> I 0..* BackboneElement  <!-- I 0..* Attests to accuracy of composition -->
  <Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict"></modifierExtension>
  <
  <
  <

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict">modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <mode><!-- I 1..1 CodeableConcept personal | professional | legal | official   --></mode>
  <time value="[dateTime]"/><!-- I 0..1 When the composition was attested -->
  <party><!-- I 0..1 Reference(Patient) 

      Who attested the composition --></party>
 </attester>
 <

 <custodian><!-- I 0..1 Reference(Organization) 

     Organization which maintains the composition --></custodian>
 <
  <<a href="clinicaldocument-definitions.html#Composition.relatesTo.modifierExtension" title="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) (this element modifies the meaning of other elements)" class="dict"></modifierExtension>
  <
  <
      Target of the relationship</target[x]>
 </relatesTo>
 <
  <<a href="clinicaldocument-definitions.html#Composition.event.modifierExtension" title="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.

 <relatesTo><!-- I 0..* RelatedArtifact 
     Relationships to other compositions/documents --></relatesTo>
 <event> I 0..* BackboneElement  <!-- I 0..* The clinical service(s) being documented -->
  <Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict"></modifierExtension>
  <</code>
  <

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict">modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <period><!-- I 0..1 Period 

      The period covered by the documentation --></period>
  <
      The event(s) being documented</detail>

  <detail><!-- I 0..* CodeableReference The event(s) being documented, as code(s), reference(s), or both icon   --></detail>

 </event>
 <
  <<a href="clinicaldocument-definitions.html#Composition.section.modifierExtension" title="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.

 <section> I 0..* BackboneElement  <!-- I 0..* Composition is broken into sections -->
  <Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict"></modifierExtension>
  <
  <</code>
  <

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict">modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <title value="[string]"/><!-- I 0..1 Label for section (e.g. for ToC) -->
  <code><!-- I 0..1 CodeableConcept Classification of section (recommended)   --></code>
  <author><!-- I 0..* Reference(Practitioner) 

      Who and/or what authored the section --></author>
  <

  <focus><!-- I 0..1 Reference(Resource) 

      Who/what the section is about, when it is not about the subject of composition --></focus>
  <

  <text><!-- I 0..1 Narrative 

      Text summary of the section, for human interpretation --></text>
  <
  <</orderedBy>
  <

  <orderedBy><!-- I 0..1 CodeableConcept Order of section entries   --></orderedBy>
  <entry><!-- I 0..* Reference(Resource) 

      A reference to data that supports this section --></entry>
  <</emptyReason>

  <emptyReason><!-- I 0..1 CodeableConcept Why the section is empty   --></emptyReason>

  <section><!-- See http://hl7.org/fhir/StructureDefinition/Composition#Composition.section  Nested Section --></section>
 </section>
</Composition>
{ // 

{ // ClinicalDocument

  // from Element: extension
    "
    "
    "
    "
    "
    " 
      { // 
        // from Element: 
      }
    ],
    "<a href="clinicaldocument-definitions.html#Composition.modifierExtension" title="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.

    "meta" : { Meta }, // IMetadata about the resource
    "implicitRules" : "<uri>", // IA set of rules under which this content was created
    "language" : "<code>", // ILanguage of the resource content
    "text" : { Narrative }, // IText summary of the resource, for human interpretation
    "contained" : [{ Resource }], //Contained, inline Resources
    "Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict">
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict">modifierExtension" : [{ Extension }], // IExtensions that cannot be ignored
    "url" : "<uri>", // ICanonical identifier for this Composition, represented as a URI (globally unique)
    "identifier" : [{ Identifier }], // IVersion-independent identifier for the Composition
    "version" : "<string>", // IAn explicitly assigned identifer of a variation of the content in the Composition
    "status" : "<code>", // I R! registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
    "type" : { CodeableConcept }, // I R! Kind of composition (LOINC if possible)
    "category" : [{ CodeableConcept }], // ICategorization of Composition
    "subject" : [{ Reference(Patient) }], // IWho and/or what the composition is about
    "encounter" : { Reference(Encounter) }, // IContext of the Composition
    "date" : "<dateTime>", // I R! Composition editing time
    "useContext" : [{ UsageContext }], // IThe context that the content is intended to support
    "author" : [{ Reference(Practitioner) }], // I R! Who and/or what authored the composition
    "name" : "<string>", // IName for this Composition (computer friendly)
    "title" : "<string>", // I R! Human Readable name/title
    "note" : [{ Annotation }], // IFor any additional notes
    "attester" : [{ BackboneElement }], // IAttests to accuracy of composition
    "custodian" : { Reference(Organization) }, // IOrganization which maintains the composition
    "relatesTo" : [{ RelatedArtifact }], // IRelationships to other compositions/documents
    "event" : [{ BackboneElement }], // IThe clinical service(s) being documented
    "section" : [{ BackboneElement }] // IComposition is broken into sections

  }

This structure is derived from Composition .

Summary

Extensions This structure refers to these extensions: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber

Differential View

This structure is derived from indicates the differences between this profile and the base Composition . structure.

composition-clinicaldocument-versionNumber 0 .. 1 string Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
Name Flags Card. Type Description & Constraints doco
. . Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
. . . subject 0 .. 1 * Reference ( Patient | Practitioner | Group | Device | Location ) Who and/or what the composition is about

doco Documentation for this format icon

Snapshot View

This provides the consolidated view (aka snapshot) of the profile after applying the changes in this profile to the base Composition structure.

0..1 Binding: Confidentiality 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 ) mode 0..1 code working | snapshot | changes Binding: ListMode ( required ): The processing mode that applies to this section. I
Name Flags Card. Type Description & Constraints doco
. . 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: Common All Languages ( preferred required ): IETF language tag for a human language

Additional Bindings Purpose All Languages 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 Additional content defined by value:url implementations
. . composition-clinicaldocument-versionNumber . modifierExtension ?! Σ 0..1 0..* string Extension Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber Extensions that cannot be ignored
. . modifierExtension . url ?! Σ 0..* 0..1 Extension uri Extensions that cannot be ignored Canonical identifier for this Composition, represented as a URI (globally unique)
. . . identifier Σ 0..1 0..* Identifier Version-independent identifier for the Composition
. . . version Σ 0..1 string An explicitly assigned identifer of a variation of the content in the Composition
... status ?! Σ 1..1 code registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
Binding: CompositionStatus Composition Status ( required ): The workflow/clinical status of the composition.

. . . type Σ 1..1 CodeableConcept Kind of composition (LOINC if possible)
Binding: FHIR Document Type Codes ( preferred ): Type of a composition.

. . . category Σ 0..* CodeableConcept Categorization of Composition
Binding: LoincDocumentOntologyInternational Referenced Item Category Value Set ( example ): High-level kind of a clinical document at a macro level.


. . . subject Σ 0..* Reference ( Patient | Practitioner | Group | Device | Location ) 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
. . . useContext Σ 0..* UsageContext The context that the content is intended to support
. . . author Σ 1..* Reference ( Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization ) Who and/or what authored the composition
. . . title name Σ 1..1 0..1 string Human Readable name/title Name for this Composition (computer friendly)
. . . confidentiality title Σ 0..1 1..1 code string As defined by affinity domain Human Readable name/title
. . . note ( required ): Codes specifying the level of confidentiality of the composition. 0..* Annotation For any additional notes
. . . 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 CodeableConcept personal | professional | legal | official
Binding: CompositionAttestationMode Composition Attestation Mode ( required preferred ): 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 0..1 Reference ( Organization ) Organization which maintains the composition
. . . relatesTo 0..* BackboneElement RelatedArtifact Relationships to other compositions/documents
. . . event Σ 0..* 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: v3 Code System ActCode ( example ): This list of codes represents the main clinical acts being documented. period Σ 0..1 Period The period covered by the documentation
. . . . detail Σ 0..* Reference CodeableReference ( Resource ) The event(s) being documented documented, as code(s), reference(s), or both
Binding: v3 Code System ActCode icon ( example ): This list of codes represents the main clinical acts being documented.


. . . section I C icon 0..* BackboneElement Composition is broken into sections
. . . . 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
. . . . title 0..1 string Label for section (e.g. for ToC)
. . . . code 0..1 CodeableConcept Classification of section (recommended)
Binding: Document Section Codes ( example ): Classification of a section of a composition/document.

. . . . 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 I C icon 0..1 Narrative Text summary of the section, for human interpretation
. . . . orderedBy 0..1 CodeableConcept Order of section entries
Binding: List Order Codes ( preferred ): What order applies to the items in the entry.

. . . . entry I C icon 0..* Reference ( Resource ) A reference to data that supports this section
. . . . emptyReason I C icon 0..1 CodeableConcept Why the section is empty
Binding: List Empty Reasons ( preferred ): If a section is empty, why it is empty.

. . . . section 0..* See section (Composition) Nested Section

doco Documentation for this format icon

XML Template

<!-- Clinical Document -->

<!-- ClinicalDocument -->doco


<Composition xmlns="http://hl7.org/fhir"
>
  <!-- from Element: extension -->
 <id value="[id]"/><!-- 0..1 Logical id of this artifact -->
 <</meta>
 <
 <
 <

 <meta><!-- I 0..1 Meta Metadata about the resource --></meta>
 <implicitRules value="[uri]"/><!-- I 0..1 A set of rules under which this content was created -->
 <language value="[code]"/><!-- I 0..1 Language of the resource content   -->
 <text><!-- I 0..1 Narrative 

     Text summary of the resource, for human interpretation --></text>
 <</contained>
 <<a href="clinicaldocument-definitions.html#Composition.modifierExtension" title="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.

 <contained><!-- 0..* Resource Contained, inline Resources --></contained>
 <Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict"></modifierExtension>
 <

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict">modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
 <url value="[uri]"/><!-- I 0..1 Canonical identifier for this Composition, represented as a URI (globally unique) -->
 <identifier><!-- I 0..* Identifier 

     Version-independent identifier for the Composition --></identifier>
 <
 <</type>
 <</category>
 <

 <version value="[string]"/><!-- I 0..1 
     An explicitly assigned identifer of a variation of the content in the Composition -->
 <status value="[code]"/><!-- I 1..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown   -->
 <type><!-- I 1..1 CodeableConcept Kind of composition (LOINC if possible)   --></type>
 <category><!-- I 0..* CodeableConcept Categorization of Composition   --></category>
 <subject><!-- I 0..* Reference(Patient) 

     Who and/or what the composition is about --></subject>
 <</encounter>
 <
 <

 <encounter><!-- I 0..1 Reference(Encounter) Context of the Composition --></encounter>
 <date value="[dateTime]"/><!-- I 1..1 Composition editing time -->
 <useContext><!-- I 0..* UsageContext 
     The context that the content is intended to support --></useContext>
 <author><!-- I 1..* Reference(Practitioner) 

     Who and/or what authored the composition --></author>
 <
 <
 <
  <<a href="clinicaldocument-definitions.html#Composition.attester.modifierExtension" title="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.

 <name value="[string]"/><!-- I 0..1 Name for this Composition (computer friendly) -->
 <title value="[string]"/><!-- I 1..1 Human Readable name/title -->
 <note><!-- I 0..* Annotation For any additional notes --></note>
 <attester> I 0..* BackboneElement  <!-- I 0..* Attests to accuracy of composition -->
  <Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict"></modifierExtension>
  <
  <
  <

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict">modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <mode><!-- I 1..1 CodeableConcept personal | professional | legal | official   --></mode>
  <time value="[dateTime]"/><!-- I 0..1 When the composition was attested -->
  <party><!-- I 0..1 Reference(Patient) 

      Who attested the composition --></party>
 </attester>
 <

 <custodian><!-- I 0..1 Reference(Organization) 

     Organization which maintains the composition --></custodian>
 <
  <<a href="clinicaldocument-definitions.html#Composition.relatesTo.modifierExtension" title="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) (this element modifies the meaning of other elements)" class="dict"></modifierExtension>
  <
  <
      Target of the relationship</target[x]>
 </relatesTo>
 <
  <<a href="clinicaldocument-definitions.html#Composition.event.modifierExtension" title="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.

 <relatesTo><!-- I 0..* RelatedArtifact 
     Relationships to other compositions/documents --></relatesTo>
 <event> I 0..* BackboneElement  <!-- I 0..* The clinical service(s) being documented -->
  <Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict"></modifierExtension>
  <</code>
  <

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict">modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <period><!-- I 0..1 Period 

      The period covered by the documentation --></period>
  <
      The event(s) being documented</detail>

  <detail><!-- I 0..* CodeableReference The event(s) being documented, as code(s), reference(s), or both icon   --></detail>

 </event>
 <
  <<a href="clinicaldocument-definitions.html#Composition.section.modifierExtension" title="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.

 <section> I 0..* BackboneElement  <!-- I 0..* Composition is broken into sections -->
  <Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict"></modifierExtension>
  <
  <</code>
  <

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict">modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <title value="[string]"/><!-- I 0..1 Label for section (e.g. for ToC) -->
  <code><!-- I 0..1 CodeableConcept Classification of section (recommended)   --></code>
  <author><!-- I 0..* Reference(Practitioner) 

      Who and/or what authored the section --></author>
  <

  <focus><!-- I 0..1 Reference(Resource) 

      Who/what the section is about, when it is not about the subject of composition --></focus>
  <

  <text><!-- I 0..1 Narrative 

      Text summary of the section, for human interpretation --></text>
  <
  <</orderedBy>
  <

  <orderedBy><!-- I 0..1 CodeableConcept Order of section entries   --></orderedBy>
  <entry><!-- I 0..* Reference(Resource) 

      A reference to data that supports this section --></entry>
  <</emptyReason>

  <emptyReason><!-- I 0..1 CodeableConcept Why the section is empty   --></emptyReason>

  <section><!-- See http://hl7.org/fhir/StructureDefinition/Composition#Composition.section  Nested Section --></section>
 </section>
</Composition>

JSON Template

{ // 

{ // ClinicalDocument

  // from Element: extension
    "
    "
    "
    "
    "
    " 
      { // 
        // from Element: 
      }
    ],
    "<a href="clinicaldocument-definitions.html#Composition.modifierExtension" title="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.

    "meta" : { Meta }, // IMetadata about the resource
    "implicitRules" : "<uri>", // IA set of rules under which this content was created
    "language" : "<code>", // ILanguage of the resource content
    "text" : { Narrative }, // IText summary of the resource, for human interpretation
    "contained" : [{ Resource }], //Contained, inline Resources
    "Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict">
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself) (this element modifies the meaning of other elements)" class="dict">modifierExtension" : [{ Extension }], // IExtensions that cannot be ignored
    "url" : "<uri>", // ICanonical identifier for this Composition, represented as a URI (globally unique)
    "identifier" : [{ Identifier }], // IVersion-independent identifier for the Composition
    "version" : "<string>", // IAn explicitly assigned identifer of a variation of the content in the Composition
    "status" : "<code>", // I R! registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
    "type" : { CodeableConcept }, // I R! Kind of composition (LOINC if possible)
    "category" : [{ CodeableConcept }], // ICategorization of Composition
    "subject" : [{ Reference(Patient) }], // IWho and/or what the composition is about
    "encounter" : { Reference(Encounter) }, // IContext of the Composition
    "date" : "<dateTime>", // I R! Composition editing time
    "useContext" : [{ UsageContext }], // IThe context that the content is intended to support
    "author" : [{ Reference(Practitioner) }], // I R! Who and/or what authored the composition
    "name" : "<string>", // IName for this Composition (computer friendly)
    "title" : "<string>", // I R! Human Readable name/title
    "note" : [{ Annotation }], // IFor any additional notes
    "attester" : [{ BackboneElement }], // IAttests to accuracy of composition
    "custodian" : { Reference(Organization) }, // IOrganization which maintains the composition
    "relatesTo" : [{ RelatedArtifact }], // IRelationships to other compositions/documents
    "event" : [{ BackboneElement }], // IThe clinical service(s) being documented
    "section" : [{ BackboneElement }] // IComposition is broken into sections

  }

 

Alternate definitions: Master Definition ( XML , JSON ), Schematron

Path Name Conformance ValueSet
Composition.language Common All Languages preferred required Common All Languages
Composition.status CompositionStatus Composition Status required CompositionStatus Composition Status
Composition.type FHIR Document Type Codes preferred FHIR Document Type Codes
Composition.category LoincDocumentOntologyInternational Referenced Item Category Value Set example LoincDocumentOntologyInternational Composition.confidentiality Confidentiality required Confidentiality Referenced Item Category Value Set
Composition.attester.mode CompositionAttestationMode Composition Attestation Mode required preferred CompositionAttestationMode Composition.relatesTo.code DocumentRelationshipType required DocumentRelationshipType Composition Attestation Mode
Composition.event.code Composition.event.detail v3 Code System ActCode example v3 Code System ActCode icon
Composition.section.code Document Section Codes example Document Section Codes
Composition.section.mode ListMode required ListMode Composition.section.orderedBy List Order Codes preferred List Order Codes
Composition.section.emptyReason List Empty Reasons preferred List Empty Reasons
. .