DSTU2 Ballot Source

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6.9.13.2 StructureDefinition: ClinicalDocument

The official URL for this profile is: 

http://hl7.org/fhir/StructureDefinition/composition-clindoc-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.

6.9.13.2.1 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 1..1CompositionA 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: Language (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 Σ0..1IdentifierLogical identifier of composition (version-independent)
... date Σ1..1dateTimeComposition editing time
... type Σ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: DocumentType (required)
... class Σ0..1CodeableConceptCategorization of Composition
Binding: DocumentC80Class (preferred)
... title Σ0..1stringHuman Readable name/title
... status ?! Σ1..1codepreliminary | final | appended | amended | entered-in-error
Binding: CompositionStatus (required)
... confidentiality ?! Σ0..1codeAs defined by affinity domain
Binding: DocumentConfidentiality (required)
... subject Σ1..1Patient, Practitioner, Group, Device, LocationWho and/or what the composition is about
... author Σ1..*Practitioner, Device, Patient, RelatedPersonWho and/or what authored the composition
... attester Σ0..*Attests to accuracy of composition
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time Σ0..1dateTimeWhen composition attested
.... party Σ0..1Patient, Practitioner, OrganizationWho attested the composition
... custodian Σ0..1OrganizationOrg which maintains the composition
... event Σ0..*The clinical service(s) being documented
.... 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 (required)
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*ResourceFull details for the event(s) the composition consents
... encounter Σ0..1EncounterContext of the conposition
... section I0..*Composition is broken into sections
cmp-1: A section must have either subsections or content
.... 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: CompositionSectionType (required)
.... content I0..1ListThe Content of the section (narrative + data entries)
.... section I0..*Nested Section

todo

This structure is derived from Composition.

Summary

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 1..1CompositionA 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: Language (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 Σ0..1IdentifierLogical identifier of composition (version-independent)
... date Σ1..1dateTimeComposition editing time
... type Σ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: DocumentType (required)
... class Σ0..1CodeableConceptCategorization of Composition
Binding: DocumentC80Class (preferred)
... title Σ0..1stringHuman Readable name/title
... status ?! Σ1..1codepreliminary | final | appended | amended | entered-in-error
Binding: CompositionStatus (required)
... confidentiality ?! Σ0..1codeAs defined by affinity domain
Binding: DocumentConfidentiality (required)
... subject Σ1..1Patient, Practitioner, Group, Device, LocationWho and/or what the composition is about
... author Σ1..*Practitioner, Device, Patient, RelatedPersonWho and/or what authored the composition
... attester Σ0..*Attests to accuracy of composition
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time Σ0..1dateTimeWhen composition attested
.... party Σ0..1Patient, Practitioner, OrganizationWho attested the composition
... custodian Σ0..1OrganizationOrg which maintains the composition
... event Σ0..*The clinical service(s) being documented
.... 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 (required)
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*ResourceFull details for the event(s) the composition consents
... encounter Σ0..1EncounterContext of the conposition
... section I0..*Composition is broken into sections
cmp-1: A section must have either subsections or content
.... 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: CompositionSectionType (required)
.... content I0..1ListThe Content of the section (narrative + data entries)
.... section I0..*Nested Section

XML Template

JSON Template

todo

 

Other representations of profile: (todo)

6.9.13.2.2 Terminology Bindings

PathNameConformanceValueSet
Composition.languageLanguagerequiredhttp://tools.ietf.org/html/bcp47
Composition.typeDocumentTyperequiredFHIR Document Type Codes
Composition.classDocumentC80ClasspreferredDocument Class Value Set
Composition.statusCompositionStatusrequiredCompositionStatus
Composition.confidentialityDocumentConfidentialityrequiredv3 Code System Confidentiality
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
Composition.event.codeDocumentEventTyperequiredv3 Code System ActCode
Composition.section.codeCompositionSectionTyperequiredDocument Section Codes

6.9.13.2.3 Constraints

IdPathNameDetails
cmp-1Composition.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)))
.