GAO Ballot Package

This page is part of the FHIR Specification (v1.1.0: STU 3 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

This is a frozen snapshot of the FHIR specification created for the purpose of balloting the GAO implementation Guide. It includes draft changes that may be part of the future DSTU 2.1 release but further change is expected. Readers should focus solely on the GAO implementation content, and FHIR DSTU 2 for other purposes.

6.8.13.2 StructureDefinition: ClinicalDocument

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.

6.8.13.2.1 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 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?! ∑0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: IETF BCP-47 (required)
... 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 ∑0..1IdentifierLogical identifier of composition (version-independent)
... date ∑1..1dateTimeComposition editing time
... type ∑1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIR Document Type Codes (preferred)
... class ∑0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... title ∑1..1stringHuman Readable name/title
... status ?! ∑1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... confidentiality ?! ∑0..1codeAs defined by affinity domain
Binding: v3 Code System Confidentiality (required)
... subject ∑1..1Reference(Patient | Practitioner | Group | Device | Location)Who and/or what the composition is about
... author ∑1..*Reference(Practitioner | Device | Patient | RelatedPerson)Who and/or what authored the composition
... attester ∑0..*BackboneElementAttests to accuracy of composition
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(Patient | Practitioner | Organization)Who attested the composition
... custodian ∑0..1Reference(Organization)Organization which maintains the composition
... event ∑0..*BackboneElementThe clinical service(s) being documented
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... code ∑0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ∑0..1PeriodThe period covered by the documentation
.... detail ∑0..*Reference(Resource)The event(s) being documented
... encounter ∑0..1Reference(Encounter)Context of the Composition
... section I0..*BackboneElementComposition is broken into sections
cmp-2: A section can only have an emptyReason if it is empty
cmp-1: A section must at least one of text, entries, or sub-sections
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*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 ?! ∑0..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..*See Composition.sectionNested Section

doco Documentation for this format

todo

This structure is derived from Composition.

Summary

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?! ∑0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: IETF BCP-47 (required)
... 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 ∑0..1IdentifierLogical identifier of composition (version-independent)
... date ∑1..1dateTimeComposition editing time
... type ∑1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIR Document Type Codes (preferred)
... class ∑0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... title ∑1..1stringHuman Readable name/title
... status ?! ∑1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... confidentiality ?! ∑0..1codeAs defined by affinity domain
Binding: v3 Code System Confidentiality (required)
... subject ∑1..1Reference(Patient | Practitioner | Group | Device | Location)Who and/or what the composition is about
... author ∑1..*Reference(Practitioner | Device | Patient | RelatedPerson)Who and/or what authored the composition
... attester ∑0..*BackboneElementAttests to accuracy of composition
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(Patient | Practitioner | Organization)Who attested the composition
... custodian ∑0..1Reference(Organization)Organization which maintains the composition
... event ∑0..*BackboneElementThe clinical service(s) being documented
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... code ∑0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ∑0..1PeriodThe period covered by the documentation
.... detail ∑0..*Reference(Resource)The event(s) being documented
... encounter ∑0..1Reference(Encounter)Context of the Composition
... section I0..*BackboneElementComposition is broken into sections
cmp-2: A section can only have an emptyReason if it is empty
cmp-1: A section must at least one of text, entries, or sub-sections
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*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 ?! ∑0..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..*See Composition.sectionNested Section

doco Documentation for this format

XML Template

JSON Template

todo

 

Other representations of profile: Schematron

6.8.13.2.2 Terminology Bindings

PathNameConformanceValueSet
Composition.language?extrequiredhttp://tools.ietf.org/html/bcp47
Composition.typeFHIR Document Type CodespreferredFHIR Document Type Codes
Composition.classFHIR Document Class CodesexampleFHIR Document Class Codes
Composition.statusCompositionStatusrequiredCompositionStatus
Composition.confidentialityv3 Code System Confidentialityrequiredv3 Code System Confidentiality
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
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

6.8.13.2.3 Constraints

IdPathDetailsRequirements
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
.