2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Profile: ClinicalDocument

The official URL for this profile is: 

http://hl7.org/fhir/Profile/cda-clinicaldocument

. Standard Profile for CDA R2 on FHIR

This profile was published on Sun, Nov 16, 2014 00:00+1100 with unknown status 'preliminary" by .

Formal Views of Profile Content

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

Differential View

This structure is derived from Composition.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 1..1Resource
... language 0..1code
... identifier 0..1IdentifierClinical Document setId
... date 1..1dateTimeCDA document date/time
... type 1..1CodeableConceptDocument Type
... class 0..0CodeableConcept
... title 0..1stringClinical Document Title
... status 1..1final
Fixed Value: final
... confidentiality M1..1CodingDocument Confidentiality
... subject 1..1#PatientRoleCDA RecordTarget
... author 1..*Practitioner, Device, Patient, RelatedPersonWho and/or what authored the composition
... attester 0..*Attests to accuracy of composition
.... mode 1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (not extensible)
.... time 0..1dateTimeWhen composition attested
.... party 0..1Patient, Practitioner, OrganizationWho attested the composition
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... custodian 0..1OrganizationOrg which maintains the composition
... event 0..1The clinical event/act/item being documented
.... code 0..*CodeableConceptCode(s) that apply to the event being documented
Binding: DocumentEventType (not extensible)
.... period 0..1PeriodThe period covered by the documentation
.... detail 0..*AnyFull details for the event(s) the composition consents
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... encounter 0..1EncounterContext of the conposition
... section I0..*Composition is broken into sections
2: A section SHALL have content or one or more sections, but not both.
.... title 0..1stringLabel for section
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: CompositionSectionType (not extensible)
.... subject M0..1Patient, Group, DeviceIf section different to composition
.... content 0..1AnyThe actual data for the section
.... section 0..*Nested Section
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... cda-inFulFillmentOf 0..*#inFulFillmentOfDiagnosticOrderCDA inFulFillmentOf

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 1..1ResourceA set of resources composed into a single coherent clinical statement with clinical attestation
... id 0..1idLogical id of this artefact
... meta 0..1MetaMetadata about the resource
... implicitRules M0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Language (required, not 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..1IdentifierClinical Document setId
... date Σ1..1dateTimeCDA document date/time
... type Σ1..1CodeableConceptDocument Type
Binding: DocumentType (preferred, extensible)
... title Σ0..1stringClinical Document Title
... status M Σ1..1codefinal
Binding: CompositionStatus (required, not extensible)
Fixed Value: final
... confidentiality M Σ1..1CodingDocument Confidentiality
Binding: DocumentConfidentiality (preferred, extensible)
... subject Σ1..1#PatientRoleCDA RecordTarget
... author Σ1..*Practitioner, Device, Patient, RelatedPersonWho and/or what authored the composition
... attester Σ0..*Attests to accuracy of composition
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (not extensible)
.... time Σ0..1dateTimeWhen composition attested
.... party Σ0..1Patient, Practitioner, OrganizationWho attested the composition
... custodian Σ0..1OrganizationOrg which maintains the composition
... event Σ0..1The clinical event/act/item being documented
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: DocumentEventType (not extensible)
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*AnyFull details for the event(s) the composition consents
... encounter Σ0..1EncounterContext of the conposition
... section I0..*Composition is broken into sections
cmp-2: A section must have either subsections or content
cmp-1: A section can only have a code if it has no content
2: A section SHALL have content or one or more sections, but not both.
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... title 0..1stringLabel for section
.... code I0..1CodeableConceptClassification of section (recommended)
Binding: CompositionSectionType (not extensible)
.... section 0..*Nested Section
.... content I0..1AnyThe Content of the section

XML Template

JSON Template

todo

Differential View

This structure is derived from Composition.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 1..1Resource
... language 0..1code
... identifier 0..1IdentifierClinical Document setId
... date 1..1dateTimeCDA document date/time
... type 1..1CodeableConceptDocument Type
... class 0..0CodeableConcept
... title 0..1stringClinical Document Title
... status 1..1final
Fixed Value: final
... confidentiality M1..1CodingDocument Confidentiality
... subject 1..1#PatientRoleCDA RecordTarget
... author 1..*Practitioner, Device, Patient, RelatedPersonWho and/or what authored the composition
... attester 0..*Attests to accuracy of composition
.... mode 1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (not extensible)
.... time 0..1dateTimeWhen composition attested
.... party 0..1Patient, Practitioner, OrganizationWho attested the composition
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... custodian 0..1OrganizationOrg which maintains the composition
... event 0..1The clinical event/act/item being documented
.... code 0..*CodeableConceptCode(s) that apply to the event being documented
Binding: DocumentEventType (not extensible)
.... period 0..1PeriodThe period covered by the documentation
.... detail 0..*AnyFull details for the event(s) the composition consents
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... encounter 0..1EncounterContext of the conposition
... section I0..*Composition is broken into sections
2: A section SHALL have content or one or more sections, but not both.
.... title 0..1stringLabel for section
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: CompositionSectionType (not extensible)
.... subject M0..1Patient, Group, DeviceIf section different to composition
.... content 0..1AnyThe actual data for the section
.... section 0..*Nested Section
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... cda-inFulFillmentOf 0..*#inFulFillmentOfDiagnosticOrderCDA inFulFillmentOf

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 1..1ResourceA set of resources composed into a single coherent clinical statement with clinical attestation
... id 0..1idLogical id of this artefact
... meta 0..1MetaMetadata about the resource
... implicitRules M0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Language (required, not 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..1IdentifierClinical Document setId
... date Σ1..1dateTimeCDA document date/time
... type Σ1..1CodeableConceptDocument Type
Binding: DocumentType (preferred, extensible)
... title Σ0..1stringClinical Document Title
... status M Σ1..1codefinal
Binding: CompositionStatus (required, not extensible)
Fixed Value: final
... confidentiality M Σ1..1CodingDocument Confidentiality
Binding: DocumentConfidentiality (preferred, extensible)
... subject Σ1..1#PatientRoleCDA RecordTarget
... author Σ1..*Practitioner, Device, Patient, RelatedPersonWho and/or what authored the composition
... attester Σ0..*Attests to accuracy of composition
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (not extensible)
.... time Σ0..1dateTimeWhen composition attested
.... party Σ0..1Patient, Practitioner, OrganizationWho attested the composition
... custodian Σ0..1OrganizationOrg which maintains the composition
... event Σ0..1The clinical event/act/item being documented
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: DocumentEventType (not extensible)
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*AnyFull details for the event(s) the composition consents
... encounter Σ0..1EncounterContext of the conposition
... section I0..*Composition is broken into sections
cmp-2: A section must have either subsections or content
cmp-1: A section can only have a code if it has no content
2: A section SHALL have content or one or more sections, but not both.
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... title 0..1stringLabel for section
.... code I0..1CodeableConceptClassification of section (recommended)
Binding: CompositionSectionType (not extensible)
.... section 0..*Nested Section
.... content I0..1AnyThe Content of the section

XML Template

JSON Template

todo

 

Other definitions: (todo)

Terminology Bindings

PathNameConformanceValueSet
Composition.languageLanguagerequiredhttp://tools.ietf.org/html/bcp47
Composition.typeDocumentTypepreferred (extensible)FHIR Document Codes
Composition.classDocumentClassexample (extensible)XDS Connect-a-thon healthcareFacilityTypeCodes
Composition.statusCompositionStatusrequiredCompositionStatus
Composition.confidentialityDocumentConfidentialitypreferred (extensible)v3 Code System Confidentiality
Composition.attester.modeCompositionAttestationModeCompositionAttestationMode
Composition.event.codeDocumentEventTypev3 Code System ActCode
Composition.section.codeCompositionSectionTypeDocument Section Codes

Constraints

IdPathNameDetails
cmp-2Composition.sectionSection ContentA section must have either subsections or content
XPath: (exists(f:content) and not(exists(f:section))) or (exists(f:section) and not(exists(f:content)))
cmp-1Composition.sectionNo section code if there's contentA section can only have a code if it has no content
XPath: not(exists(f:code)) or not(exists(f:content))
2Composition.sectionSection RuleA section SHALL have content or one or more sections, but not both.
XPath: exists(f:content) != exists(f:section)
.