DSTU2 QA Preview

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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)Org 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 conposition
... 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..1CodeableConceptWhat order the section entries are in
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..*Nested 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)Org 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 conposition
... 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..1CodeableConceptWhat order the section entries are in
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..*Nested 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)
.