Release 5 Preview #2

This page is part of the FHIR Specification (v4.4.0: R5 Preview #2). 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: R5 R4B

2.42.18.2 StructureDefinition: EvidenceReport

Structured Documents Work Group Maturity Level: 1Trial Use Use Context: Any

The official URL for this profile is: 

http://hl7.org/fhir/StructureDefinition/evidencereport

A set of resources composed into a single coherent clinical statement with clinical attestation

This profile was published on Thu, Apr 30, 2020 00:00+1000 as a draft by Health Level Seven, Inc. - Clinical Decision Support WG.

2.42.18.2.1 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

Mandatory: 2 elements
Fixed Value: 1 element
Prohibited: 5 elements

This structure is derived from Composition.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... type 1..1CodeableConceptThe type of document - an Evidence Report
Fixed Value: As shown
.... text1..1stringPlain text representation of the concept
Fixed Value: EvidenceReport
... subject 0..1Reference(EvidenceFocus)Who and/or what the composition is about
... encounter 0..0
... attester 0..*BackboneElementAttests to accuracy of composition
.... party 0..1Reference(RelatedPerson | Organization)Who reviewed, edited or approved
... event 0..0
... section 0..*BackboneElementComposition is broken into sections
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: EvidenceReportSectionCode (extensible)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1idLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..1IdentifierVersion-independent identifier for the Composition
... status ?!ΣI1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type ΣI1..1CodeableConceptThe type of document - an Evidence Report
Binding: FHIR Document Type Codes (preferred)
Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding0..0CodingCode defined by a terminology system
.... text1..1stringPlain text representation of the concept
Fixed Value: EvidenceReport
... category ΣI0..*CodeableConceptCategorization of Composition
Binding: Document Class Value Set (example)
... subject ΣI0..1Reference(EvidenceFocus)Who and/or what the composition is about
... date ΣI1..1dateTimeComposition editing time
... author ΣI1..*Reference(Device | RelatedPerson | Organization)Who created the evidence report
... title ΣI1..1stringHuman Readable name/title
... confidentiality ΣI0..1codeAs defined by affinity domain
Binding: ConfidentialityClassification (required)
... attester I0..*BackboneElementAttests to accuracy of composition
.... id 0..1idUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode I1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time I0..1dateTimeWhen the composition was attested
.... party I0..1Reference(RelatedPerson | Organization)Who reviewed, edited or approved
... custodian ΣI0..1Reference(Organization)Organization which maintains the composition
... relatesTo I0..*BackboneElementRelationships to other compositions/documents
.... id 0..1idUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code I1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] I1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... section I0..*BackboneElementComposition is broken into sections
.... id 0..1idUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title I0..1stringLabel for section (e.g. for ToC)
.... code I0..1CodeableConceptClassification of section (recommended)
Binding: EvidenceReportSectionCode (extensible)
.... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy I0..1CodeableConceptOrder of section entries
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..*Unknown reference to #Composition.section
Nested Section

doco Documentation for this format
<!-- Evidence Report -->doco

<Composition xmlns="http://hl7.org/fhir"
>
  <!-- from Element: extension -->
 <id value="[id]"/><!-- 0..1 Logical id of this artifact -->
 <meta><!-- ?? 0..1 Meta Metadata about the resource --></meta>
 <implicitRules value="[uri]"/><!-- ?? 0..1 A set of rules under which this content was created -->
 <language value="[code]"/><!-- ?? 0..1 Language of the resource content   -->
 <text><!-- ?? 0..1 Narrative 
     Text summary of the resource, for human interpretation --></text>
 <contained><!-- 0..* Resource Contained, inline Resources --></contained>
 <modifierExtension><!-- ?? 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
 <identifier><!-- ?? 0..1 Identifier 
     Version-independent identifier for the Composition --></identifier>
 <status value="[code]"/><!-- ?? 1..1 preliminary | final | amended | entered-in-error   -->
 <type><!-- ?? 1..1 CodeableConcept The type of document - an Evidence Report   --></type>
 <category><!-- ?? 0..* CodeableConcept Categorization of Composition   --></category>
 <subject><!-- ?? 0..1 Reference(EvidenceFocus) 
     Who and/or what the composition is about --></subject>
 <encounter><!-- ?? 0..0 Reference(Encounter) Context of the Composition --></encounter>
 <date value="[dateTime]"/><!-- ?? 1..1 Composition editing time -->
 <author><!-- ?? 1..* Reference(Device) Who created the evidence report --></author>
 <title value="[string]"/><!-- ?? 1..1 Human Readable name/title -->
 <confidentiality value="[code]"/><!-- ?? 0..1 As defined by affinity domain   -->
 <attester> ?? 0..* BackboneElement  <!-- ?? 0..* Attests to accuracy of composition -->
  <modifierExtension><!-- ?? 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <mode value="[code]"/><!-- ?? 1..1 personal | professional | legal | official   -->
  <time value="[dateTime]"/><!-- ?? 0..1 When the composition was attested -->
  <party><!-- ?? 0..1 Reference(RelatedPerson) 
      Who reviewed, edited or approved --></party>
 </attester>
 <custodian><!-- ?? 0..1 Reference(Organization) 
     Organization which maintains the composition --></custodian>
 <relatesTo> ?? 0..* BackboneElement  <!-- ?? 0..* Relationships to other compositions/documents -->
  <modifierExtension><!-- ?? 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <code value="[code]"/><!-- ?? 1..1 replaces | transforms | signs | appends   -->
  <target[x]><!-- ?? 1..1 Identifier|Reference(Composition) 
      Target of the relationship --></target[x]>
 </relatesTo>
 <event> ?? 0..0 BackboneElement  <!-- ?? 0..0 The clinical service(s) being documented -->
 </event>
 <section> ?? 0..* BackboneElement  <!-- ?? 0..* Composition is broken into sections -->
  <modifierExtension><!-- ?? 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <title value="[string]"/><!-- ?? 0..1 Label for section (e.g. for ToC) -->
  <code><!-- ?? 0..1 CodeableConcept Classification of section (recommended)   --></code>
  <author><!-- ?? 0..* Reference(Practitioner) 
      Who and/or what authored the section --></author>
  <focus><!-- ?? 0..1 Reference(Resource) 
      Who/what the section is about, when it is not about the subject of composition --></focus>
  <text><!-- ?? 0..1 Narrative 
      Text summary of the section, for human interpretation --></text>
  <mode value="[code]"/><!-- ?? 0..1 working | snapshot | changes   -->
  <orderedBy><!-- ?? 0..1 CodeableConcept Order of section entries   --></orderedBy>
  <entry><!-- ?? 0..* Reference(Resource) 
      A reference to data that supports this section --></entry>
  <emptyReason><!-- ?? 0..1 CodeableConcept Why the section is empty   --></emptyReason>
  <section><!-- See #Composition.section  Nested Section --></section>
 </section>
</Composition>

{ // Evidence Report
  // from Element: extension
    "meta" : { Meta }, // C?Metadata about the resource
    "implicitRules" : "<uri>", // C?A set of rules under which this content was created
    "language" : "<code>", // C?Language of the resource content
    "text" : { Narrative }, // C?Text summary of the resource, for human interpretation
    "contained" : [{ Resource }], //Contained, inline Resources
    "modifierExtension" : [{ Extension }], // C?Extensions that cannot be ignored
    "identifier" : { Identifier }, // C?Version-independent identifier for the Composition
    "status" : "<code>", // C? R! preliminary | final | amended | entered-in-error
    "type" : { CodeableConcept }, // C? R! 
    "category" : [{ CodeableConcept }], // C?Categorization of Composition
    "subject" : { Reference(EvidenceFocus) }, // C?Who and/or what the composition is about
    "date" : "<dateTime>", // C? R! Composition editing time
    "author" : [{ Reference(Device) }], // C? R! Who created the evidence report
    "title" : "<string>", // C? R! Human Readable name/title
    "confidentiality" : "<code>", // C?As defined by affinity domain
    "attester" : [{ BackboneElement }], // C?Attests to accuracy of composition
    "custodian" : { Reference(Organization) }, // C?Organization which maintains the composition
    "relatesTo" : [{ BackboneElement }], // C?Relationships to other compositions/documents
    "section" : [{ BackboneElement }] // C?Composition is broken into sections
  }

This structure is derived from Composition.

Summary

Mandatory: 2 elements
Fixed Value: 1 element
Prohibited: 5 elements

Differential View

This structure is derived from Composition.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... type 1..1CodeableConceptThe type of document - an Evidence Report
Fixed Value: As shown
.... text1..1stringPlain text representation of the concept
Fixed Value: EvidenceReport
... subject 0..1Reference(EvidenceFocus)Who and/or what the composition is about
... encounter 0..0
... attester 0..*BackboneElementAttests to accuracy of composition
.... party 0..1Reference(RelatedPerson | Organization)Who reviewed, edited or approved
... event 0..0
... section 0..*BackboneElementComposition is broken into sections
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: EvidenceReportSectionCode (extensible)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1idLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..1IdentifierVersion-independent identifier for the Composition
... status ?!ΣI1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type ΣI1..1CodeableConceptThe type of document - an Evidence Report
Binding: FHIR Document Type Codes (preferred)
Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding0..0CodingCode defined by a terminology system
.... text1..1stringPlain text representation of the concept
Fixed Value: EvidenceReport
... category ΣI0..*CodeableConceptCategorization of Composition
Binding: Document Class Value Set (example)
... subject ΣI0..1Reference(EvidenceFocus)Who and/or what the composition is about
... date ΣI1..1dateTimeComposition editing time
... author ΣI1..*Reference(Device | RelatedPerson | Organization)Who created the evidence report
... title ΣI1..1stringHuman Readable name/title
... confidentiality ΣI0..1codeAs defined by affinity domain
Binding: ConfidentialityClassification (required)
... attester I0..*BackboneElementAttests to accuracy of composition
.... id 0..1idUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode I1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time I0..1dateTimeWhen the composition was attested
.... party I0..1Reference(RelatedPerson | Organization)Who reviewed, edited or approved
... custodian ΣI0..1Reference(Organization)Organization which maintains the composition
... relatesTo I0..*BackboneElementRelationships to other compositions/documents
.... id 0..1idUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code I1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] I1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... section I0..*BackboneElementComposition is broken into sections
.... id 0..1idUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title I0..1stringLabel for section (e.g. for ToC)
.... code I0..1CodeableConceptClassification of section (recommended)
Binding: EvidenceReportSectionCode (extensible)
.... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy I0..1CodeableConceptOrder of section entries
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..*Unknown reference to #Composition.section
Nested Section

doco Documentation for this format

XML Template

<!-- Evidence Report -->doco

<Composition xmlns="http://hl7.org/fhir"
>
  <!-- from Element: extension -->
 <id value="[id]"/><!-- 0..1 Logical id of this artifact -->
 <meta><!-- ?? 0..1 Meta Metadata about the resource --></meta>
 <implicitRules value="[uri]"/><!-- ?? 0..1 A set of rules under which this content was created -->
 <language value="[code]"/><!-- ?? 0..1 Language of the resource content   -->
 <text><!-- ?? 0..1 Narrative 
     Text summary of the resource, for human interpretation --></text>
 <contained><!-- 0..* Resource Contained, inline Resources --></contained>
 <modifierExtension><!-- ?? 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
 <identifier><!-- ?? 0..1 Identifier 
     Version-independent identifier for the Composition --></identifier>
 <status value="[code]"/><!-- ?? 1..1 preliminary | final | amended | entered-in-error   -->
 <type><!-- ?? 1..1 CodeableConcept The type of document - an Evidence Report   --></type>
 <category><!-- ?? 0..* CodeableConcept Categorization of Composition   --></category>
 <subject><!-- ?? 0..1 Reference(EvidenceFocus) 
     Who and/or what the composition is about --></subject>
 <encounter><!-- ?? 0..0 Reference(Encounter) Context of the Composition --></encounter>
 <date value="[dateTime]"/><!-- ?? 1..1 Composition editing time -->
 <author><!-- ?? 1..* Reference(Device) Who created the evidence report --></author>
 <title value="[string]"/><!-- ?? 1..1 Human Readable name/title -->
 <confidentiality value="[code]"/><!-- ?? 0..1 As defined by affinity domain   -->
 <attester> ?? 0..* BackboneElement  <!-- ?? 0..* Attests to accuracy of composition -->
  <modifierExtension><!-- ?? 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <mode value="[code]"/><!-- ?? 1..1 personal | professional | legal | official   -->
  <time value="[dateTime]"/><!-- ?? 0..1 When the composition was attested -->
  <party><!-- ?? 0..1 Reference(RelatedPerson) 
      Who reviewed, edited or approved --></party>
 </attester>
 <custodian><!-- ?? 0..1 Reference(Organization) 
     Organization which maintains the composition --></custodian>
 <relatesTo> ?? 0..* BackboneElement  <!-- ?? 0..* Relationships to other compositions/documents -->
  <modifierExtension><!-- ?? 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <code value="[code]"/><!-- ?? 1..1 replaces | transforms | signs | appends   -->
  <target[x]><!-- ?? 1..1 Identifier|Reference(Composition) 
      Target of the relationship --></target[x]>
 </relatesTo>
 <event> ?? 0..0 BackboneElement  <!-- ?? 0..0 The clinical service(s) being documented -->
 </event>
 <section> ?? 0..* BackboneElement  <!-- ?? 0..* Composition is broken into sections -->
  <modifierExtension><!-- ?? 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <title value="[string]"/><!-- ?? 0..1 Label for section (e.g. for ToC) -->
  <code><!-- ?? 0..1 CodeableConcept Classification of section (recommended)   --></code>
  <author><!-- ?? 0..* Reference(Practitioner) 
      Who and/or what authored the section --></author>
  <focus><!-- ?? 0..1 Reference(Resource) 
      Who/what the section is about, when it is not about the subject of composition --></focus>
  <text><!-- ?? 0..1 Narrative 
      Text summary of the section, for human interpretation --></text>
  <mode value="[code]"/><!-- ?? 0..1 working | snapshot | changes   -->
  <orderedBy><!-- ?? 0..1 CodeableConcept Order of section entries   --></orderedBy>
  <entry><!-- ?? 0..* Reference(Resource) 
      A reference to data that supports this section --></entry>
  <emptyReason><!-- ?? 0..1 CodeableConcept Why the section is empty   --></emptyReason>
  <section><!-- See #Composition.section  Nested Section --></section>
 </section>
</Composition>

JSON Template

{ // Evidence Report
  // from Element: extension
    "meta" : { Meta }, // C?Metadata about the resource
    "implicitRules" : "<uri>", // C?A set of rules under which this content was created
    "language" : "<code>", // C?Language of the resource content
    "text" : { Narrative }, // C?Text summary of the resource, for human interpretation
    "contained" : [{ Resource }], //Contained, inline Resources
    "modifierExtension" : [{ Extension }], // C?Extensions that cannot be ignored
    "identifier" : { Identifier }, // C?Version-independent identifier for the Composition
    "status" : "<code>", // C? R! preliminary | final | amended | entered-in-error
    "type" : { CodeableConcept }, // C? R! 
    "category" : [{ CodeableConcept }], // C?Categorization of Composition
    "subject" : { Reference(EvidenceFocus) }, // C?Who and/or what the composition is about
    "date" : "<dateTime>", // C? R! Composition editing time
    "author" : [{ Reference(Device) }], // C? R! Who created the evidence report
    "title" : "<string>", // C? R! Human Readable name/title
    "confidentiality" : "<code>", // C?As defined by affinity domain
    "attester" : [{ BackboneElement }], // C?Attests to accuracy of composition
    "custodian" : { Reference(Organization) }, // C?Organization which maintains the composition
    "relatesTo" : [{ BackboneElement }], // C?Relationships to other compositions/documents
    "section" : [{ BackboneElement }] // C?Composition is broken into sections
  }

 

Alternate definitions: Master Definition (XML, JSON), Schematron

2.42.18.2.2 Terminology Bindings

PathNameConformanceValueSet
Composition.languageCommon LanguagespreferredCommon Languages
Composition.statusCompositionStatusrequiredCompositionStatus
Composition.typeFHIR Document Type CodespreferredFHIR Document Type Codes
Composition.categoryDocument Class Value SetexampleDocument Class Value Set
Composition.confidentialityV3 Value SetConfidentialityClassificationrequiredV3 Value SetConfidentialityClassification
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
Composition.relatesTo.codeDocumentRelationshipTyperequiredDocumentRelationshipType
Composition.section.codeEvidenceReportSectionCodeextensibleEvidenceReportSectionCode
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
.