R4 Draft for Comment

This page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

2.41.11.2 StructureDefinition: ClinicalDocument

(No assigned work group) Maturity Level: 1Informative Use Context: Any

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.

2.41.11.2.1 Formal Views of Profile Content

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

This structure is derived from Composition.

Summary

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*A set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierLogical identifier of composition (version-independent)
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type Σ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIR Document Type Codes (preferred)
... class Σ0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... subject Σ0..1Reference(Patient), Reference(Practitioner), Reference(Group), Reference(Device), Reference(Location)Who and/or what the composition is about
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date Σ1..1dateTimeComposition editing time
... author Σ1..*Reference(Practitioner), Reference(PractitionerRole), Reference(Device), Reference(Patient), Reference(RelatedPerson), Reference(Organization)Who and/or what authored the composition
... title Σ1..1stringHuman Readable name/title
... confidentiality ?!Σ0..1codeAs defined by affinity domain
Binding: ConfidentialityClassification (required)
... attester ΣI0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time Σ0..1dateTimeWhen the composition was attested
.... party Σ0..1Reference(Patient), Reference(Practitioner), Reference(PractitionerRole), Reference(Organization)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo ΣI0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] Σ1..1Identifier, Reference(Composition)Target of the relationship
... event ΣI0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section I0..*BackboneElementComposition 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: Document Section Codes (example)
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section
Nested Section

doco Documentation for this format
<!-- Clinical Document Profile for Composition -->doco

<Composition xmlns="http://hl7.org/fhir"
>
  <!-- from Element: extension -->
 <id value="[id]"/><!-- 0..1 Logical id of this artifact -->
 <meta><!-- 0..1 Meta Metadata about the resource --></meta>
 <implicitRules value="[uri]"/><!-- 0..1 A set of rules under which this content was created -->
 <language value="[code]"/><!-- 0..1 Language of the resource content  -->
 <text><!-- 0..1 Narrative 
     Text summary of the resource, for human interpretation --></text>
 <contained><!-- 0..* Resource Contained, inline Resources --></contained>
 <modifierExtension><!-- 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
 <identifier><!-- 0..1 Identifier 
     Logical identifier of composition (version-independent) --></identifier>
 <status value="[code]"/><!-- 1..1 preliminary | final | amended | entered-in-error  -->
 <type><!-- 1..1 CodeableConcept Kind of composition (LOINC if possible)  --></type>
 <class><!-- 0..1 CodeableConcept Categorization of Composition  --></class>
 <subject><!-- 0..1 Reference(Patient)|Reference(Practitioner)|Reference(Group)|Reference(Device)|
   Reference(Location) Who and/or what the composition is about --></subject>
 <encounter><!-- 0..1 Reference(Encounter) Context of the Composition --></encounter>
 <date value="[dateTime]"/><!-- 1..1 Composition editing time -->
 <author><!-- 1..* Reference(Practitioner)|Reference(PractitionerRole)|Reference(Device)|Reference(Patient)|Reference(RelatedPerson)|
   Reference(Organization) Who and/or what authored the composition --></author>
 <title value="[string]"/><!-- 1..1 Human Readable name/title -->
 <confidentiality value="[code]"/><!-- 0..1 As defined by affinity domain  -->
 <attester> ?? 0..* BackboneElement  <!-- ?? 0..* Attests to accuracy of composition -->
  <modifierExtension><!-- 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
  <mode value="[code]"/><!-- 1..* personal | professional | legal | official  -->
  <time value="[dateTime]"/><!-- 0..1 When the composition was attested -->
  <party><!-- 0..1 Reference(Patient)|Reference(Practitioner)|Reference(PractitionerRole)|Reference(Organization) 
      Who attested the composition --></party>
 </attester>
 <custodian><!-- 0..1 Reference(Organization) 
     Organization which maintains the composition --></custodian>
 <relatesTo> ?? 0..* BackboneElement  <!-- ?? 0..* Relationships to other compositions/documents -->
  <modifierExtension><!-- 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
  <code value="[code]"/><!-- 1..1 replaces | transforms | signs | appends  -->
  <target[x]><!-- 1..1 Identifier|Reference(Composition) 
      Target of the relationship --></target[x]>
 </relatesTo>
 <event> ?? 0..* BackboneElement  <!-- ?? 0..* The clinical service(s) being documented -->
  <modifierExtension><!-- 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
  <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..* Reference(Resource) 
      The event(s) being documented --></detail>
 </event>
 <section> ?? 0..* BackboneElement  <!-- ?? 0..* Composition is broken into sections -->
  <modifierExtension><!-- 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
  <title value="[string]"/><!-- 0..1 Label for section (e.g. for ToC) -->
  <code><!-- 0..1 CodeableConcept Classification of section (recommended)  --></code>
  <text><!-- 0..1 Narrative 
      Text summary of the section, for human interpretation --></text>
  <mode value="[code]"/><!-- 0..1 working | snapshot | changes  -->
  <orderedBy><!-- 0..1 CodeableConcept Order of section entries  --></orderedBy>
  <entry><!-- 0..* Reference(Resource) 
      A reference to data that supports this section --></entry>
  <emptyReason><!-- 0..1 CodeableConcept Why the section is empty  --></emptyReason>
  <section><!-- See #Composition.section  Nested Section --></section>
 </section>
</Composition>

{ // Clinical Document Profile for Composition
  // from Element: extension
    "meta" : { Meta }, //Metadata about the resource
    "implicitRules" : "<uri>", //A set of rules under which this content was created
    "language" : "<code>", //Language of the resource content 
    "text" : { Narrative }, //Text summary of the resource, for human interpretation
    "contained" : [{ Resource }], //Contained, inline Resources
    "modifierExtension" : [{ Extension }], //Extensions that cannot be ignored
    "identifier" : { Identifier }, //Logical identifier of composition (version-independent)
    "status" : "<code>", // R! preliminary | final | amended | entered-in-error 
    "type" : { CodeableConcept }, // R! Kind of composition (LOINC if possible) 
    "class" : { CodeableConcept }, //Categorization of Composition 
// value[x]: Who and/or what the composition is about. One of these 5:
    "subject" : { Reference(Patient) }, //Who and/or what the composition is about
    "subject" : { Reference(Practitioner) }, //Who and/or what the composition is about
    "subject" : { Reference(Group) }, //Who and/or what the composition is about
    "subject" : { Reference(Device) }, //Who and/or what the composition is about
    "subject" : { Reference(Location) }, //Who and/or what the composition is about
    "encounter" : { Reference(Encounter) }, //Context of the Composition
    "date" : "<dateTime>", // R! Composition editing time
// value[x]: Who and/or what authored the composition. One of these 6:
    "author" : [{ Reference(Practitioner) }], // R! Who and/or what authored the composition
    "author" : [{ Reference(PractitionerRole) }], // R! Who and/or what authored the composition
    "author" : [{ Reference(Device) }], // R! Who and/or what authored the composition
    "author" : [{ Reference(Patient) }] // R! Who and/or what authored the composition
    "author" : [{ Reference(RelatedPerson) }], // R! Who and/or what authored the composition
    "author" : [{ Reference(Organization) }], // R! Who and/or what authored the composition
    "title" : "<string>", // R! Human Readable name/title
    "confidentiality" : "<code>", //As defined by affinity domain 
    "attester" : [{ BackboneElement }], // C?Attests to accuracy of composition
    "custodian" : { Reference(Organization) }, //Organization which maintains the composition
    "relatesTo" : [{ BackboneElement }], // C?Relationships to other compositions/documents
    "event" : [{ BackboneElement }], // C?The clinical service(s) being documented
    "section" : [{ BackboneElement }], // C?Composition is broken into sections
  }

This structure is derived from Composition.

Summary

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*A set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierLogical identifier of composition (version-independent)
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type Σ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIR Document Type Codes (preferred)
... class Σ0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... subject Σ0..1Reference(Patient), Reference(Practitioner), Reference(Group), Reference(Device), Reference(Location)Who and/or what the composition is about
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date Σ1..1dateTimeComposition editing time
... author Σ1..*Reference(Practitioner), Reference(PractitionerRole), Reference(Device), Reference(Patient), Reference(RelatedPerson), Reference(Organization)Who and/or what authored the composition
... title Σ1..1stringHuman Readable name/title
... confidentiality ?!Σ0..1codeAs defined by affinity domain
Binding: ConfidentialityClassification (required)
... attester ΣI0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time Σ0..1dateTimeWhen the composition was attested
.... party Σ0..1Reference(Patient), Reference(Practitioner), Reference(PractitionerRole), Reference(Organization)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo ΣI0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] Σ1..1Identifier, Reference(Composition)Target of the relationship
... event ΣI0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section I0..*BackboneElementComposition 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..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: Document Section Codes (example)
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode ?!Σ0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition.section
Nested Section

doco Documentation for this format

XML Template

<!-- Clinical Document Profile for Composition -->doco

<Composition xmlns="http://hl7.org/fhir"
>
  <!-- from Element: extension -->
 <id value="[id]"/><!-- 0..1 Logical id of this artifact -->
 <meta><!-- 0..1 Meta Metadata about the resource --></meta>
 <implicitRules value="[uri]"/><!-- 0..1 A set of rules under which this content was created -->
 <language value="[code]"/><!-- 0..1 Language of the resource content  -->
 <text><!-- 0..1 Narrative 
     Text summary of the resource, for human interpretation --></text>
 <contained><!-- 0..* Resource Contained, inline Resources --></contained>
 <modifierExtension><!-- 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
 <identifier><!-- 0..1 Identifier 
     Logical identifier of composition (version-independent) --></identifier>
 <status value="[code]"/><!-- 1..1 preliminary | final | amended | entered-in-error  -->
 <type><!-- 1..1 CodeableConcept Kind of composition (LOINC if possible)  --></type>
 <class><!-- 0..1 CodeableConcept Categorization of Composition  --></class>
 <subject><!-- 0..1 Reference(Patient)|Reference(Practitioner)|Reference(Group)|Reference(Device)|
   Reference(Location) Who and/or what the composition is about --></subject>
 <encounter><!-- 0..1 Reference(Encounter) Context of the Composition --></encounter>
 <date value="[dateTime]"/><!-- 1..1 Composition editing time -->
 <author><!-- 1..* Reference(Practitioner)|Reference(PractitionerRole)|Reference(Device)|Reference(Patient)|Reference(RelatedPerson)|
   Reference(Organization) Who and/or what authored the composition --></author>
 <title value="[string]"/><!-- 1..1 Human Readable name/title -->
 <confidentiality value="[code]"/><!-- 0..1 As defined by affinity domain  -->
 <attester> ?? 0..* BackboneElement  <!-- ?? 0..* Attests to accuracy of composition -->
  <modifierExtension><!-- 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
  <mode value="[code]"/><!-- 1..* personal | professional | legal | official  -->
  <time value="[dateTime]"/><!-- 0..1 When the composition was attested -->
  <party><!-- 0..1 Reference(Patient)|Reference(Practitioner)|Reference(PractitionerRole)|Reference(Organization) 
      Who attested the composition --></party>
 </attester>
 <custodian><!-- 0..1 Reference(Organization) 
     Organization which maintains the composition --></custodian>
 <relatesTo> ?? 0..* BackboneElement  <!-- ?? 0..* Relationships to other compositions/documents -->
  <modifierExtension><!-- 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
  <code value="[code]"/><!-- 1..1 replaces | transforms | signs | appends  -->
  <target[x]><!-- 1..1 Identifier|Reference(Composition) 
      Target of the relationship --></target[x]>
 </relatesTo>
 <event> ?? 0..* BackboneElement  <!-- ?? 0..* The clinical service(s) being documented -->
  <modifierExtension><!-- 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
  <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..* Reference(Resource) 
      The event(s) being documented --></detail>
 </event>
 <section> ?? 0..* BackboneElement  <!-- ?? 0..* Composition is broken into sections -->
  <modifierExtension><!-- 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
  <title value="[string]"/><!-- 0..1 Label for section (e.g. for ToC) -->
  <code><!-- 0..1 CodeableConcept Classification of section (recommended)  --></code>
  <text><!-- 0..1 Narrative 
      Text summary of the section, for human interpretation --></text>
  <mode value="[code]"/><!-- 0..1 working | snapshot | changes  -->
  <orderedBy><!-- 0..1 CodeableConcept Order of section entries  --></orderedBy>
  <entry><!-- 0..* Reference(Resource) 
      A reference to data that supports this section --></entry>
  <emptyReason><!-- 0..1 CodeableConcept Why the section is empty  --></emptyReason>
  <section><!-- See #Composition.section  Nested Section --></section>
 </section>
</Composition>

JSON Template

{ // Clinical Document Profile for Composition
  // from Element: extension
    "meta" : { Meta }, //Metadata about the resource
    "implicitRules" : "<uri>", //A set of rules under which this content was created
    "language" : "<code>", //Language of the resource content 
    "text" : { Narrative }, //Text summary of the resource, for human interpretation
    "contained" : [{ Resource }], //Contained, inline Resources
    "modifierExtension" : [{ Extension }], //Extensions that cannot be ignored
    "identifier" : { Identifier }, //Logical identifier of composition (version-independent)
    "status" : "<code>", // R! preliminary | final | amended | entered-in-error 
    "type" : { CodeableConcept }, // R! Kind of composition (LOINC if possible) 
    "class" : { CodeableConcept }, //Categorization of Composition 
// value[x]: Who and/or what the composition is about. One of these 5:
    "subject" : { Reference(Patient) }, //Who and/or what the composition is about
    "subject" : { Reference(Practitioner) }, //Who and/or what the composition is about
    "subject" : { Reference(Group) }, //Who and/or what the composition is about
    "subject" : { Reference(Device) }, //Who and/or what the composition is about
    "subject" : { Reference(Location) }, //Who and/or what the composition is about
    "encounter" : { Reference(Encounter) }, //Context of the Composition
    "date" : "<dateTime>", // R! Composition editing time
// value[x]: Who and/or what authored the composition. One of these 6:
    "author" : [{ Reference(Practitioner) }], // R! Who and/or what authored the composition
    "author" : [{ Reference(PractitionerRole) }], // R! Who and/or what authored the composition
    "author" : [{ Reference(Device) }], // R! Who and/or what authored the composition
    "author" : [{ Reference(Patient) }] // R! Who and/or what authored the composition
    "author" : [{ Reference(RelatedPerson) }], // R! Who and/or what authored the composition
    "author" : [{ Reference(Organization) }], // R! Who and/or what authored the composition
    "title" : "<string>", // R! Human Readable name/title
    "confidentiality" : "<code>", //As defined by affinity domain 
    "attester" : [{ BackboneElement }], // C?Attests to accuracy of composition
    "custodian" : { Reference(Organization) }, //Organization which maintains the composition
    "relatesTo" : [{ BackboneElement }], // C?Relationships to other compositions/documents
    "event" : [{ BackboneElement }], // C?The clinical service(s) being documented
    "section" : [{ BackboneElement }], // C?Composition is broken into sections
  }

 

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

2.41.11.2.2 Terminology Bindings

PathNameConformanceValueSet
Composition.languageCommon LanguagesextensibleCommon Languages
Composition.statusCompositionStatusrequiredCompositionStatus
Composition.typeFHIR Document Type CodespreferredFHIR Document Type Codes
Composition.classFHIR Document Class CodesexampleFHIR Document Class Codes
Composition.confidentialityConfidentialityClassificationrequiredConfidentialityClassification
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
Composition.relatesTo.codeDocumentRelationshipTyperequiredDocumentRelationshipType
Composition.event.codev3 Code System ActCodeexamplev3 Code System ActCode
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons

2.41.11.2.3 Constraints

IdPathDetailsRequirements
cmp-1Composition.sectionA section must contain at least one of text, entries, or sub-sections
Expression : text.exists() or entry.exists() or section.exists()
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
Expression : emptyReason.empty() or entry.empty()
.