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 . Page versions: R4 R3
A clinical document is a documentation of clinical observations and services, with the following characteristics: (1) Persistence - A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements; (2) Stewardship - A clinical document is maintained by a person or organization entrusted with its care; (3) Potential for authentication - A clinical document is an assemblage of information that is intended to be legally authenticated; (4) Wholeness - Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document; (5) Human readability - A clinical document is human readable."
<ValueSet xmlns="http://hl7.org/fhir"> <id value="v3-ActClassClinicalDocument"/> <meta> <lastUpdated value="2016-03-31T08:01:25.570+11:00"/> <profile value="http://hl7.org/fhir/StructureDefinition/valueset-shareable-definition"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <h2>ActClassClinicalDocument</h2> <p> A clinical document is a documentation of clinical observations and services, with the following characteristics: (1) Persistence - A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements; (2) Stewardship - A clinical document is maintained by a person or organization entrusted with its care; (3) Potential for authentication - A clinical document is an assemblage of information that is intended to be legally authenticated; (4) Wholeness - Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document; (5) Human readability - A clinical document is human readable."</p> <p>This value set includes codes from the following code systems:</p> <ul> <li>Include codes from <a href="../../v3/ActClass/cs.html">http://hl7.org/fhir/v3/ActClass</a> where concept is-a <a href="../../v3/ActClass/cs.html#DOCCLIN">DOCCLIN</a> </li> </ul> </div> </text> <extension url="http://hl7.org/fhir/StructureDefinition/valueset-oid"> <valueUri value="urn:oid:2.16.840.1.113883.1.11.13948"/> </extension> <url value="http://hl7.org/fhir/ValueSet/v3-ActClassClinicalDocument"/> <version value="2014-03-26"/> <name value="ActClassClinicalDocument"/> <status value="active"/> <experimental value="false"/> <publisher value="HL7 v3"/> <contact> <telecom> <system value="other"/> <value value="http://www.hl7.org"/> </telecom> </contact> <description value=" A clinical document is a documentation of clinical observations and services, with the following characteristics: (1) Persistence - A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements; (2) Stewardship - A clinical document is maintained by a person or organization entrusted with its care; (3) Potential for authentication - A clinical document is an assemblage of information that is intended to be legally authenticated; (4) Wholeness - Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document; (5) Human readability - A clinical document is human readable.""/> <compose> <include> <system value="http://hl7.org/fhir/v3/ActClass"/> <filter> <property value="concept"/> <op value="is-a"/> <value value="DOCCLIN"/> </filter> </include> </compose> </ValueSet>
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.