STU 3 Candidate
This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
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ClinicalDocument
<StructureDefinition xmlns="http://hl7.org/fhir"> <id value="clinicaldocument"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">to do</div> </text> <url value="http://hl7.org/fhir/StructureDefinition/clinicaldocument"/> <name value="Clinical Document Profile for Composition"/> <status value="draft"/> <publisher value="Health Level Seven, Inc. - Structured Documents WG"/> <contact> <telecom> <system value="other"/> <value value="http://hl7.org/special/committees/structure"/> </telecom> </contact> <date value="2015-03-17"/> <description value="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"/> <fhirVersion value="1.4.0"/> <kind value="resource"/> <abstract value="false"/> <baseType value="Composition"/> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/Composition"/> <derivation value="constraint"/> <snapshot> <element> <path value="Composition"/> <name value="ClinicalDocument"/> <short value="A set of resources composed into a single coherent clinical statement with clinical attestation"/> <definition value="A set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained."/> <comments value="While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical."/> <min value="0"/> <max value="*"/> <base> <path value="Composition"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Composition"/> </type> <mapping> <identity value="cda"/> <map value="ClinicalDocument"/> </mapping> <mapping> <identity value="rim"/> <map value="Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]"/> </mapping> <mapping> <identity value="w5"/> <map value="infrastructure.documents"/> </mapping> </element> <element> <path value="Composition.id"/> <short value="Logical id of this artifact"/> <definition value="The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes."/> <comments value="The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID."/> <min value="0"/> <max value="1"/> <base> <path value="Resource.id"/> <min value="0"/> <max value="*"/> </base> <type> <code value="id"/> </type> <isSummary value="true"/> </element> <element> <path value="Composition.meta"/> <short value="Metadata about the resource"/> <definition value="The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource."/> <min value="0"/> <max value="1"/> <base> <path value="Resource.meta"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Meta"/> </type> <isSummary value="true"/> </element> <element> <path value="Composition.implicitRules"/> <short value="A set of rules under which this content was created"/> <definition value="A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content."/> <comments value="Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible."/> <min value="0"/> <max value="1"/> <base> <path value="Resource.implicitRules"/> <min value="0"/> <max value="*"/> </base> <type> <code value="uri"/> </type> <isModifier value="true"/> <isSummary value="true"/> </element> <element> <path value="Composition.language"/> <short value="Language of the resource content"/> <definition value="The base language in which the resource is written."/> <comments value="Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute)."/> <min value="0"/> <max value="1"/> <base> <path value="Resource.language"/> <min value="0"/> <max value="*"/> </base> <type> <code value="code"/> </type> <binding> <strength value="required"/> <description value="A human language."/> <valueSetUri value="http://tools.ietf.org/html/bcp47"/> </binding> </element> <element> <path value="Composition.text"/> <short value="Text summary of the resource, for human interpretation"/> <definition value="A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety."/> <comments value="Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative."/> <alias value="narrative"/> <alias value="html"/> <alias value="xhtml"/> <alias value="display"/> <min value="0"/> <max value="1"/> <base> <path value="DomainResource.text"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Narrative"/> </type> <condition value="dom-1"/> <mapping> <identity value="rim"/> <map value="Act.text?"/> </mapping> </element> <element> <path value="Composition.contained"/> <short value="Contained, inline Resources"/> <definition value="These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope."/> <comments value="This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again."/> <alias value="inline resources"/> <alias value="anonymous resources"/> <alias value="contained resources"/> <min value="0"/> <max value="*"/> <base> <path value="DomainResource.contained"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Resource"/> </type> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="Composition.extension"/> <short value="Additional Content defined by implementations"/> <definition value="May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension."/> <comments value="There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone."/> <alias value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="DomainResource.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="Composition.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions."/> <comments value="There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone."/> <alias value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="DomainResource.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="Composition.identifier"/> <short value="Logical identifier of composition (version-independent)"/> <definition value="Logical identifier for the composition, assigned when created. This identifier stays constant as the composition is changed over time."/> <comments value="See discussion in resource definition for how these relate."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.identifier"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Identifier"/> </type> <isSummary value="true"/> <mapping> <identity value="cda"/> <map value=".setId"/> </mapping> <mapping> <identity value="rim"/> <map value="Document.id / Document.setId"/> </mapping> <mapping> <identity value="w5"/> <map value="id"/> </mapping> </element> <element> <path value="Composition.date"/> <short value="Composition editing time"/> <definition value="The composition editing time, when the composition was last logically changed by the author."/> <comments value="The Last Modified Date on the composition may be after the date of the document was attested without being changed."/> <requirements value="dateTime is used for tracking, organizing versions and searching."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.date"/> <min value="1"/> <max value="1"/> </base> <type> <code value="dateTime"/> </type> <isSummary value="true"/> <mapping> <identity value="cda"/> <map value=".effectiveTime"/> </mapping> <mapping> <identity value="rim"/> <map value=".effectiveTime[type="TS"]"/> </mapping> <mapping> <identity value="w5"/> <map value="when.done"/> </mapping> </element> <element> <path value="Composition.type"/> <short value="Kind of composition (LOINC if possible)"/> <definition value="Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition."/> <comments value="For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding."/> <requirements value="Key metadata element describing the composition, used in searching/filtering."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.type"/> <min value="1"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <isSummary value="true"/> <binding> <strength value="preferred"/> <description value="Type of a composition."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-typecodes"/> </valueSetReference> </binding> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element> <path value="Composition.class"/> <short value="Categorization of Composition"/> <definition value="A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type."/> <comments value="This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_ Documents_(MHD))."/> <requirements value="Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.class"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <isSummary value="true"/> <binding> <strength value="example"/> <description value="High-level kind of a clinical document at a macro level."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-classcodes"/> </valueSetReference> </binding> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN&quo t;].code"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element> <path value="Composition.title"/> <short value="Human Readable name/title"/> <definition value="Official human-readable label for the composition."/> <comments value="For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.title"/> <min value="1"/> <max value="1"/> </base> <type> <code value="string"/> </type> <isSummary value="true"/> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> </element> <element> <path value="Composition.status"/> <short value="preliminary | final | amended | entered-in-error"/> <definition value="The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document."/> <comments value="If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "withdrawn" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required."/> <requirements value="Need to be able to mark interim, amended, or withdrawn compositions or documents."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.status"/> <min value="1"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The workflow/clinical status of the composition."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/composition-status"/> </valueSetReference> </binding> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="rim"/> <map value="interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete&q uot; and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[su bsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseCompo sition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ " and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNo rmalDatatype()]="obsolete""/> </mapping> <mapping> <identity value="w5"/> <map value="status"/> </mapping> </element> <element> <path value="Composition.confidentiality"/> <short value="As defined by affinity domain"/> <definition value="The code specifying the level of confidentiality of the Composition."/> <comments value="The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section)."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.confidentiality"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="Codes specifying the level of confidentiality of the composition."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/v3-Confidentiality"/> </valueSetReference> </binding> <mapping> <identity value="cda"/> <map value=".confidentialityCode"/> </mapping> <mapping> <identity value="rim"/> <map value=".confidentialityCode"/> </mapping> </element> <element> <path value="Composition.subject"/> <short value="Who and/or what the composition is about"/> <definition value="Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure)."/> <comments value="For clinical documents, this is usually the patient."/> <requirements value="Essential metadata for searching for the composition. Identifies who and/or what the composition/doc ument is about."/> <min value="1"/> <max value="1"/> <base> <path value="Composition.subject"/> <min value="1"/> <max value="1"/> </base> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Patient"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Practitioner"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Group"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Device"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Location"/> </type> <isSummary value="true"/> <mapping> <identity value="cda"/> <map value=".recordTarget"/> </mapping> <mapping> <identity value="rim"/> <map value=".participation[typeCode="SBJ"].role[typeCode="PAT"]"/> </mapping> <mapping> <identity value="w5"/> <map value="who.focus"/> </mapping> </element> <element> <path value="Composition.author"/> <short value="Who and/or what authored the composition"/> <definition value="Identifies who is responsible for the information in the composition, not necessarily who typed it in."/> <requirements value="Identifies who is responsible for the content."/> <min value="1"/> <max value="*"/> <base> <path value="Composition.author"/> <min value="1"/> <max value="*"/> </base> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Practitioner"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Device"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Patient"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/RelatedPerson"/> </type> <isSummary value="true"/> <mapping> <identity value="cda"/> <map value=".author.assignedAuthor"/> </mapping> <mapping> <identity value="rim"/> <map value=".participation[typeCode="AUT"].role[classCode="ASSIGNED"]"/> </mapping> <mapping> <identity value="w5"/> <map value="who.author"/> </mapping> </element> <element> <path value="Composition.attester"/> <short value="Attests to accuracy of composition"/> <definition value="A participant who has attested to the accuracy of the composition/document."/> <comments value="Only list each attester once."/> <requirements value="Identifies responsibility for the accuracy of the composition content."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.attester"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <isSummary value="true"/> <mapping> <identity value="cda"/> <map value=".authenticator/.legalAuthenticator"/> </mapping> <mapping> <identity value="rim"/> <map value=".participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]"/> </mapping> </element> <element> <path value="Composition.attester.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references)."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="*"/> </base> <type> <code value="id"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="Composition.attester.extension"/> <short value="Additional Content defined by implementations"/> <definition value="May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension."/> <comments value="There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone."/> <alias value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="Composition.attester.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions."/> <comments value="There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone."/> <alias value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="Composition.attester.mode"/> <short value="personal | professional | legal | official"/> <definition value="The type of attestation the authenticator offers."/> <comments value="Use more than one code where a single attester has more than one mode (professional and legal are often paired)."/> <requirements value="Indicates the level of authority of the attestation."/> <min value="1"/> <max value="*"/> <base> <path value="Composition.attester.mode"/> <min value="1"/> <max value="*"/> </base> <type> <code value="code"/> </type> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The way in which a person authenticated a composition."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/composition-attestation-mode"/> </valueSetReference> </binding> <mapping> <identity value="cda"/> <map value="implied by .authenticator/.legalAuthenticator"/> </mapping> <mapping> <identity value="rim"/> <map value="unique(./modeCode)"/> </mapping> </element> <element> <path value="Composition.attester.time"/> <short value="When composition attested"/> <definition value="When composition was attested by the party."/> <requirements value="Identifies when the information in the composition was deemed accurate. (Things may have changed since then.)."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.attester.time"/> <min value="0"/> <max value="1"/> </base> <type> <code value="dateTime"/> </type> <isSummary value="true"/> <mapping> <identity value="cda"/> <map value=".authenticator.time"/> </mapping> <mapping> <identity value="rim"/> <map value="./time[type="TS" and isNormalDatatype()]"/> </mapping> </element> <element> <path value="Composition.attester.party"/> <short value="Who attested the composition"/> <definition value="Who attested the composition in the specified way."/> <requirements value="Identifies who has taken on the responsibility for accuracy of the composition content."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.attester.party"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Patient"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Practitioner"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Organization"/> </type> <isSummary value="true"/> <mapping> <identity value="cda"/> <map value=".authenticator.assignedEnttty"/> </mapping> <mapping> <identity value="rim"/> <map value="./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASS IGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]"/> </mapping> <mapping> <identity value="w5"/> <map value="who.witness"/> </mapping> </element> <element> <path value="Composition.custodian"/> <short value="Organization which maintains the composition"/> <definition value="Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information."/> <comments value="This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However it is important that this information be known when working with a derived document, so providing a custodian is encouraged."/> <requirements value="Identifies where to go to find the current version, where to report issues, etc."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.custodian"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Organization"/> </type> <isSummary value="true"/> <mapping> <identity value="cda"/> <map value=".custodian.assignedCustodian"/> </mapping> <mapping> <identity value="rim"/> <map value=".participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG " and determinerCode="INST"]"/> </mapping> </element> <element> <path value="Composition.event"/> <short value="The clinical service(s) being documented"/> <definition value="The clinical service, such as a colonoscopy or an appendectomy, being documented."/> <comments value="The event needs to be consistent with the type element, though can provide further information if desired."/> <requirements value="Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.event"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <isSummary value="true"/> <mapping> <identity value="cda"/> <map value=".documentationOf.serviceEvent"/> </mapping> <mapping> <identity value="rim"/> <map value="outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']"/> </mapping> </element> <element> <path value="Composition.event.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references)."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="*"/> </base> <type> <code value="id"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="Composition.event.extension"/> <short value="Additional Content defined by implementations"/> <definition value="May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension."/> <comments value="There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone."/> <alias value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="Composition.event.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions."/> <comments value="There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone."/> <alias value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="Composition.event.code"/> <short value="Code(s) that apply to the event being documented"/> <definition value="This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act."/> <comments value="An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.event.code"/> <min value="0"/> <max value="*"/> </base> <type> <code value="CodeableConcept"/> </type> <isSummary value="true"/> <binding> <strength value="example"/> <description value="This list of codes represents the main clinical acts being documented."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/v3-ActCode"/> </valueSetReference> </binding> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> <mapping> <identity value="rim"/> <map value=".code"/> </mapping> </element> <element> <path value="Composition.event.period"/> <short value="The period covered by the documentation"/> <definition value="The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.event.period"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Period"/> </type> <isSummary value="true"/> <mapping> <identity value="cda"/> <map value=".effectiveTime"/> </mapping> <mapping> <identity value="rim"/> <map value=".effectiveTime"/> </mapping> </element> <element> <path value="Composition.event.detail"/> <short value="The event(s) being documented"/> <definition value="The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.event.detail"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <isSummary value="true"/> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode="SUBJ"].target"/> </mapping> </element> <element> <path value="Composition.encounter"/> <short value="Context of the Composition"/> <definition value="Describes the clinical encounter or type of care this documentation is associated with."/> <requirements value="Provides context for the composition and supports searching."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.encounter"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/> </type> <isSummary value="true"/> <mapping> <identity value="cda"/> <map value=".componentOf.encompassingEncounter"/> </mapping> <mapping> <identity value="rim"/> <map value="unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])"/> </mapping> <mapping> <identity value="w5"/> <map value="context"/> </mapping> </element> <element id="section"> <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name"> <valueString value="Section"/> </extension> <path value="Composition.section"/> <short value="Composition is broken into sections"/> <definition value="The root of the sections that make up the composition."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section"/> <min value="0"/> <max value="*"/> </base> <type> <code value="BackboneElement"/> </type> <constraint> <key value="cmp-2"/> <severity value="error"/> <human value="A section can only have an emptyReason if it is empty"/> <expression value="emptyReason.empty() or entry.empty()"/> <xpath value="not(exists(f:emptyReason) and exists(f:entry))"/> </constraint> <constraint> <key value="cmp-1"/> <severity value="error"/> <human value="A section must at least one of text, entries, or sub-sections"/> <expression value="text or entry or section"/> <xpath value="exists(f:text) or exists(f:entry) or exists(f:section)"/> </constraint> <mapping> <identity value="cda"/> <map value=".component.structuredBody.component.section"/> </mapping> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode=&quo t;EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> </element> <element> <path value="Composition.section.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references)."/> <min value="0"/> <max value="1"/> <base> <path value="Element.id"/> <min value="0"/> <max value="*"/> </base> <type> <code value="id"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="Composition.section.extension"/> <short value="Additional Content defined by implementations"/> <definition value="May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension."/> <comments value="There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone."/> <alias value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <base> <path value="Element.extension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="Composition.section.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions."/> <comments value="There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone."/> <alias value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <base> <path value="BackboneElement.modifierExtension"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Extension"/> </type> <isModifier value="true"/> <isSummary value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="Composition.section.title"/> <short value="Label for section (e.g. for ToC)"/> <definition value="The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents."/> <comments value="The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element."/> <requirements value="Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized."/> <alias value="header"/> <alias value="label"/> <alias value="caption"/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.title"/> <min value="0"/> <max value="1"/> </base> <type> <code value="string"/> </type> <mapping> <identity value="cda"/> <map value=".title"/> </mapping> <mapping> <identity value="rim"/> <map value="./title"/> </mapping> </element> <element> <path value="Composition.section.code"/> <short value="Classification of section (recommended)"/> <definition value="A code identifying the kind of content contained within the section. This must be consistent with the section title."/> <comments value="The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code."/> <requirements value="Provides computable standardized labels to topics within the document."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.code"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="example"/> <description value="Classification of a section of a composition/document."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> </valueSetReference> </binding> <mapping> <identity value="cda"/> <map value=".code"/> </mapping> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> </element> <element> <path value="Composition.section.text"/> <short value="Text summary of the section, for human interpretation"/> <definition value="A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative."/> <comments value="Document profiles may define what content should be represented in the narrative to ensure clinical safety."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.text"/> <min value="0"/> <max value="1"/> </base> <type> <code value="Narrative"/> </type> <condition value="cmp-1"/> <mapping> <identity value="cda"/> <map value=".text"/> </mapping> <mapping> <identity value="rim"/> <map value=".text"/> </mapping> </element> <element> <path value="Composition.section.mode"/> <short value="working | snapshot | changes"/> <definition value="How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted."/> <requirements value="Sections are used in various ways, and it must be known in what way it is safe to use the entries in them."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.mode"/> <min value="0"/> <max value="1"/> </base> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <strength value="required"/> <description value="The processing mode that applies to this section."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-mode"/> </valueSetReference> </binding> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="rim"/> <map value=".outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value"/> </mapping> <mapping> <identity value="w5"/> <map value="class"/> </mapping> </element> <element> <path value="Composition.section.orderedBy"/> <short value="Order of section entries"/> <definition value="Specifies the order applied to the items in the section entries."/> <comments value="Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order."/> <requirements value="Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.orderedBy"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <binding> <strength value="preferred"/> <description value="What order applies to the items in the entry."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-order"/> </valueSetReference> </binding> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP].sequenceNumber > 1"/> </mapping> </element> <element> <path value="Composition.section.entry"/> <short value="A reference to data that supports this section"/> <definition value="A reference to the actual resource from which the narrative in the section is derived."/> <comments value="If there are no entries in the list, an emptyReason SHOULD be provided."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.entry"/> <min value="0"/> <max value="*"/> </base> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <condition value="cmp-2"/> <mapping> <identity value="cda"/> <map value=".entry"/> </mapping> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]"/> </mapping> </element> <element> <path value="Composition.section.emptyReason"/> <short value="Why the section is empty"/> <definition value="If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason."/> <comments value="The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases."/> <requirements value="Allows capturing things like "none exist" or "not asked" which can be important for most lists."/> <min value="0"/> <max value="1"/> <base> <path value="Composition.section.emptyReason"/> <min value="0"/> <max value="1"/> </base> <type> <code value="CodeableConcept"/> </type> <condition value="cmp-2"/> <binding> <strength value="preferred"/> <description value="If a section is empty, why it is empty."/> <valueSetReference> <reference value="http://hl7.org/fhir/ValueSet/list-empty-reason"/> </valueSetReference> </binding> <mapping> <identity value="cda"/> <map value="n/a"/> </mapping> <mapping> <identity value="rim"/> <map value=".inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD]"/> </mapping> </element> <element> <path value="Composition.section.section"/> <short value="Nested Section"/> <definition value="A nested sub-section within this section."/> <comments value="Nested sections are primarily used to help human readers navigate to particular portions of the document."/> <min value="0"/> <max value="*"/> <base> <path value="Composition.section.section"/> <min value="0"/> <max value="*"/> </base> <contentReference value="#section"/> <condition value="cmp-1"/> <mapping> <identity value="cda"/> <map value=".component.section"/> </mapping> <mapping> <identity value="rim"/> <map value="./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode=&quo t;EVN" and classCode="DOCSECT" and isNormalAct]"/> </mapping> </element> </snapshot> <differential> <element> <path value="Composition"/> <name value="ClinicalDocument"/> <min value="0"/> <max value="*"/> <type> <code value="Composition"/> </type> </element> <element> <path value="Composition.subject"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Patient"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Practitioner"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Group"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Device"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Location"/> </type> </element> </differential> </StructureDefinition>
© HL7.org 2011+. FHIR STU3 Candidate (v1.4.0-8139) generated on Thu, Mar 31, 2016 08:08+1100. QA Page
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