StructureDefinition: Clinical Document

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2.8.15.2 StructureDefinition: Clinical Document

Structured Documents icon

Work Group

Maturity Level: 0

Trial Use

Use Context: Any

The canonical URL for this profile is:

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

The Clinical Document profile constrains Composition to specify a clinical document (matching CDA). 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 requirements around confidentiality that do not apply in the same way to other kinds of documents.

This profile was published on Thu, Jan 1, 1970 00:00+1000 as a draft by HL7.

2.8.15.2.1 Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

Text Summary
Differential View
Full Structure
XML Template
JSON Template
All

This structure is derived from Composition.

Summary

Extensions

This structure refers to these extensions:

http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber

This indicates the differences between this profile and the base Composition structure.

Name	Card.	Type	Description & Constraints
Composition	0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
versionNumber	0..1	string	Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
subject	0..*	Reference(Patient \| Practitioner \| Group \| Device \| Location)	Who and/or what the composition is about
Documentation for this format

This provides the consolidated view (aka snapshot) of the profile after applying the changes in this profile to the base Composition structure.

Description & Constraints

Composition

0..*

Composition

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

0..1

Logical id of this artifact

category

0..*

CodeableConcept

Categorization of Composition
Binding: Referenced Item Category Value Set (example): High-level kind of a clinical document at a macro level.

subject

0..*

Reference(Patient | Practitioner | Group | Device | Location)

Who and/or what the composition is about

encounter

0..1

Reference(Encounter)

Context of the Composition

date

1..1

dateTime

Composition editing time

useContext

0..*

UsageContext

The context that the content is intended to support

author

1..*

Who and/or what authored the composition

name

0..1

string

Name for this Composition (computer friendly)

title

1..1

string

Human Readable name/title

note

0..*

Annotation

For any additional notes

attester

0..*

BackboneElement

Attests to accuracy of composition

0..1

string

Unique id for inter-element referencing

extension

0..*

Extension

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extension

Extensions that cannot be ignored even if unrecognized

mode

1..1

CodeableConcept

personal | professional | legal | official
Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a composition.

time

0..1

dateTime

When the composition was attested

party

0..1

Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)

Who attested the composition

custodian

0..1

Reference(Organization)

Organization which maintains the composition

relatesTo

0..*

RelatedArtifact

Relationships to other compositions/documents

event

0..*

BackboneElement

The clinical service(s) being documented

0..1

string

Unique id for inter-element referencing

extension

0..*

Extension

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extension

Extensions that cannot be ignored even if unrecognized

code

0..*

CodeableConcept

Code(s) that apply to the event being documented
Binding: v3 Code System ActCode icon

(example): This list of codes represents the main clinical acts being documented.

period

0..1

Period

The period covered by the documentation

detail

0..*

Reference(Resource)

The event(s) being documented

section

0..*

BackboneElement

Composition is broken into sections

0..1

string

Unique id for inter-element referencing

extension

0..*

Extension

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extension

Extensions that cannot be ignored even if unrecognized

title

0..1

string

Label for section (e.g. for ToC)

code

0..1

CodeableConcept

Classification of section (recommended)
Binding: Document Section Codes (example): Classification of a section of a composition/document.

author

0..*

Who and/or what authored the section

focus

0..1

Reference(Resource)

Who/what the section is about, when it is not about the subject of composition

text

0..1

Narrative

Text summary of the section, for human interpretation

mode

0..1

code

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

orderedBy

0..1

CodeableConcept

Order of section entries
Binding: List Order Codes (preferred): What order applies to the items in the entry.

entry

0..*

Reference(Resource)

A reference to data that supports this section

emptyReason

0..1

CodeableConcept

Why the section is empty
Binding: List Empty Reasons (preferred): If a section is empty, why it is empty.

section

0..*

See section (Composition)

Nested Section

Documentation for this format

<!-- Clinical Document -->

<Composition xmlns="http://hl7.org/fhir"
>
  <!-- from Element: extension -->
 <id value="[id]"/><!-- 0..1 Logical id of this artifact -->
 <meta><!-- I 0..1 Meta Metadata about the resource --></meta>
 <implicitRules value="[uri]"/><!-- I 0..1 A set of rules under which this content was created -->
 <language value="[code]"/><!-- I 0..1 Language of the resource content   -->
 <text><!-- I 0..1 Narrative 
     Text summary of the resource, for human interpretation --></text>
 <contained><!-- 0..* Resource Contained, inline Resources --></contained>
 <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
 <url value="[uri]"/><!-- I 0..1 Canonical identifier for this Composition, represented as a URI (globally unique) -->
 <identifier><!-- I 0..* Identifier 
     Version-independent identifier for the Composition --></identifier>
 <version value="[string]"/><!-- I 0..1 
     An explicitly assigned identifer of a variation of the content in the Composition -->
 <status value="[code]"/><!-- I 1..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown   -->
 <type><!-- I 1..1 CodeableConcept Kind of composition (LOINC if possible)   --></type>
 <category><!-- I 0..* CodeableConcept Categorization of Composition   --></category>
 <subject><!-- I 0..* Reference(Patient) 
     Who and/or what the composition is about --></subject>
 <encounter><!-- I 0..1 Reference(Encounter) Context of the Composition --></encounter>
 <date value="[dateTime]"/><!-- I 1..1 Composition editing time -->
 <useContext><!-- I 0..* UsageContext 
     The context that the content is intended to support --></useContext>
 <author><!-- I 1..* Reference(Practitioner) 
     Who and/or what authored the composition --></author>
 <name value="[string]"/><!-- I 0..1 Name for this Composition (computer friendly) -->
 <title value="[string]"/><!-- I 1..1 Human Readable name/title -->
 <note><!-- I 0..* Annotation For any additional notes --></note>
 <attester> I 0..* BackboneElement  <!-- I 0..* Attests to accuracy of composition -->
  <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <mode><!-- I 1..1 CodeableConcept personal | professional | legal | official   --></mode>
  <time value="[dateTime]"/><!-- I 0..1 When the composition was attested -->
  <party><!-- I 0..1 Reference(Patient) 
      Who attested the composition --></party>
 </attester>
 <custodian><!-- I 0..1 Reference(Organization) 
     Organization which maintains the composition --></custodian>
 <relatesTo><!-- I 0..* RelatedArtifact 
     Relationships to other compositions/documents --></relatesTo>
 <event> I 0..* BackboneElement  <!-- I 0..* The clinical service(s) being documented -->
  <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <code><!-- I 0..* CodeableConcept Code(s) that apply to the event being documented    --></code>
  <period><!-- I 0..1 Period 
      The period covered by the documentation --></period>
  <detail><!-- I 0..* Reference(Resource) 
      The event(s) being documented --></detail>
 </event>
 <section> I 0..* BackboneElement  <!-- I 0..* Composition is broken into sections -->
  <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <title value="[string]"/><!-- I 0..1 Label for section (e.g. for ToC) -->
  <code><!-- I 0..1 CodeableConcept Classification of section (recommended)   --></code>
  <author><!-- I 0..* Reference(Practitioner) 
      Who and/or what authored the section --></author>
  <focus><!-- I 0..1 Reference(Resource) 
      Who/what the section is about, when it is not about the subject of composition --></focus>
  <text><!-- I 0..1 Narrative 
      Text summary of the section, for human interpretation --></text>
  <mode value="[code]"/><!-- I 0..1 working | snapshot | changes   -->
  <orderedBy><!-- I 0..1 CodeableConcept Order of section entries   --></orderedBy>
  <entry><!-- I 0..* Reference(Resource) 
      A reference to data that supports this section --></entry>
  <emptyReason><!-- I 0..1 CodeableConcept Why the section is empty   --></emptyReason>
  <section><!-- See http://hl7.org/fhir/StructureDefinition/Composition#Composition.section  Nested Section --></section>
 </section>
</Composition>

{ // Clinical Document
  // from Element: extension
    "meta" : { Meta }, // IMetadata about the resource
    "implicitRules" : "<uri>", // IA set of rules under which this content was created
    "language" : "<code>", // ILanguage of the resource content
    "text" : { Narrative }, // IText summary of the resource, for human interpretation
    "contained" : [{ Resource }], //Contained, inline Resources
    "extension" : [ //  sliced by value:url  in the specified order, Open 
      { // Version-specific identifier for composition // I
        // from Element: extension
      }
    ],
    "modifierExtension" : [{ Extension }], // IExtensions that cannot be ignored
    "url" : "<uri>", // ICanonical identifier for this Composition, represented as a URI (globally unique)
    "identifier" : [{ Identifier }], // IVersion-independent identifier for the Composition
    "version" : "<string>", // IAn explicitly assigned identifer of a variation of the content in the Composition
    "status" : "<code>", // I R! registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
    "type" : { CodeableConcept }, // I R! Kind of composition (LOINC if possible)
    "category" : [{ CodeableConcept }], // ICategorization of Composition
    "subject" : [{ Reference(Patient) }], // IWho and/or what the composition is about
    "encounter" : { Reference(Encounter) }, // IContext of the Composition
    "date" : "<dateTime>", // I R! Composition editing time
    "useContext" : [{ UsageContext }], // IThe context that the content is intended to support
    "author" : [{ Reference(Practitioner) }], // I R! Who and/or what authored the composition
    "name" : "<string>", // IName for this Composition (computer friendly)
    "title" : "<string>", // I R! Human Readable name/title
    "note" : [{ Annotation }], // IFor any additional notes
    "attester" : [{ BackboneElement }], // IAttests to accuracy of composition
    "custodian" : { Reference(Organization) }, // IOrganization which maintains the composition
    "relatesTo" : [{ RelatedArtifact }], // IRelationships to other compositions/documents
    "event" : [{ BackboneElement }], // IThe clinical service(s) being documented
    "section" : [{ BackboneElement }], // IComposition is broken into sections
  }

This structure is derived from Composition.

Summary

Extensions

This structure refers to these extensions:

http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber

Differential View

This indicates the differences between this profile and the base Composition structure.

Name	Card.	Type	Description & Constraints
Composition	0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
versionNumber	0..1	string	Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
subject	0..*	Reference(Patient \| Practitioner \| Group \| Device \| Location)	Who and/or what the composition is about
Documentation for this format

Snapshot View

This provides the consolidated view (aka snapshot) of the profile after applying the changes in this profile to the base Composition structure.

Description & Constraints

Composition

0..*

Composition

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

0..1

Logical id of this artifact

category

0..*

CodeableConcept

Categorization of Composition
Binding: Referenced Item Category Value Set (example): High-level kind of a clinical document at a macro level.

subject

0..*

Reference(Patient | Practitioner | Group | Device | Location)

Who and/or what the composition is about

encounter

0..1

Reference(Encounter)

Context of the Composition

date

1..1

dateTime

Composition editing time

useContext

0..*

UsageContext

The context that the content is intended to support

author

1..*

Who and/or what authored the composition

name

0..1

string

Name for this Composition (computer friendly)

title

1..1

string

Human Readable name/title

note

0..*

Annotation

For any additional notes

attester

0..*

BackboneElement

Attests to accuracy of composition

0..1

string

Unique id for inter-element referencing

extension

0..*

Extension

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extension

Extensions that cannot be ignored even if unrecognized

mode

1..1

CodeableConcept

personal | professional | legal | official
Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a composition.

time

0..1

dateTime

When the composition was attested

party

0..1

Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)

Who attested the composition

custodian

0..1

Reference(Organization)

Organization which maintains the composition

relatesTo

0..*

RelatedArtifact

Relationships to other compositions/documents

event

0..*

BackboneElement

The clinical service(s) being documented

0..1

string

Unique id for inter-element referencing

extension

0..*

Extension

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extension

Extensions that cannot be ignored even if unrecognized

code

0..*

CodeableConcept

Code(s) that apply to the event being documented
Binding: v3 Code System ActCode icon

(example): This list of codes represents the main clinical acts being documented.

period

0..1

Period

The period covered by the documentation

detail

0..*

Reference(Resource)

The event(s) being documented

section

0..*

BackboneElement

Composition is broken into sections

0..1

string

Unique id for inter-element referencing

extension

0..*

Extension

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extension

Extensions that cannot be ignored even if unrecognized

title

0..1

string

Label for section (e.g. for ToC)

code

0..1

CodeableConcept

Classification of section (recommended)
Binding: Document Section Codes (example): Classification of a section of a composition/document.

author

0..*

Who and/or what authored the section

focus

0..1

Reference(Resource)

Who/what the section is about, when it is not about the subject of composition

text

0..1

Narrative

Text summary of the section, for human interpretation

mode

0..1

code

working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

orderedBy

0..1

CodeableConcept

Order of section entries
Binding: List Order Codes (preferred): What order applies to the items in the entry.

entry

0..*

Reference(Resource)

A reference to data that supports this section

emptyReason

0..1

CodeableConcept

Why the section is empty
Binding: List Empty Reasons (preferred): If a section is empty, why it is empty.

section

0..*

See section (Composition)

Nested Section

Documentation for this format

XML Template

<!-- Clinical Document -->

<Composition xmlns="http://hl7.org/fhir"
>
  <!-- from Element: extension -->
 <id value="[id]"/><!-- 0..1 Logical id of this artifact -->
 <meta><!-- I 0..1 Meta Metadata about the resource --></meta>
 <implicitRules value="[uri]"/><!-- I 0..1 A set of rules under which this content was created -->
 <language value="[code]"/><!-- I 0..1 Language of the resource content   -->
 <text><!-- I 0..1 Narrative 
     Text summary of the resource, for human interpretation --></text>
 <contained><!-- 0..* Resource Contained, inline Resources --></contained>
 <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
 <url value="[uri]"/><!-- I 0..1 Canonical identifier for this Composition, represented as a URI (globally unique) -->
 <identifier><!-- I 0..* Identifier 
     Version-independent identifier for the Composition --></identifier>
 <version value="[string]"/><!-- I 0..1 
     An explicitly assigned identifer of a variation of the content in the Composition -->
 <status value="[code]"/><!-- I 1..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown   -->
 <type><!-- I 1..1 CodeableConcept Kind of composition (LOINC if possible)   --></type>
 <category><!-- I 0..* CodeableConcept Categorization of Composition   --></category>
 <subject><!-- I 0..* Reference(Patient) 
     Who and/or what the composition is about --></subject>
 <encounter><!-- I 0..1 Reference(Encounter) Context of the Composition --></encounter>
 <date value="[dateTime]"/><!-- I 1..1 Composition editing time -->
 <useContext><!-- I 0..* UsageContext 
     The context that the content is intended to support --></useContext>
 <author><!-- I 1..* Reference(Practitioner) 
     Who and/or what authored the composition --></author>
 <name value="[string]"/><!-- I 0..1 Name for this Composition (computer friendly) -->
 <title value="[string]"/><!-- I 1..1 Human Readable name/title -->
 <note><!-- I 0..* Annotation For any additional notes --></note>
 <attester> I 0..* BackboneElement  <!-- I 0..* Attests to accuracy of composition -->
  <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <mode><!-- I 1..1 CodeableConcept personal | professional | legal | official   --></mode>
  <time value="[dateTime]"/><!-- I 0..1 When the composition was attested -->
  <party><!-- I 0..1 Reference(Patient) 
      Who attested the composition --></party>
 </attester>
 <custodian><!-- I 0..1 Reference(Organization) 
     Organization which maintains the composition --></custodian>
 <relatesTo><!-- I 0..* RelatedArtifact 
     Relationships to other compositions/documents --></relatesTo>
 <event> I 0..* BackboneElement  <!-- I 0..* The clinical service(s) being documented -->
  <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <code><!-- I 0..* CodeableConcept Code(s) that apply to the event being documented    --></code>
  <period><!-- I 0..1 Period 
      The period covered by the documentation --></period>
  <detail><!-- I 0..* Reference(Resource) 
      The event(s) being documented --></detail>
 </event>
 <section> I 0..* BackboneElement  <!-- I 0..* Composition is broken into sections -->
  <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <title value="[string]"/><!-- I 0..1 Label for section (e.g. for ToC) -->
  <code><!-- I 0..1 CodeableConcept Classification of section (recommended)   --></code>
  <author><!-- I 0..* Reference(Practitioner) 
      Who and/or what authored the section --></author>
  <focus><!-- I 0..1 Reference(Resource) 
      Who/what the section is about, when it is not about the subject of composition --></focus>
  <text><!-- I 0..1 Narrative 
      Text summary of the section, for human interpretation --></text>
  <mode value="[code]"/><!-- I 0..1 working | snapshot | changes   -->
  <orderedBy><!-- I 0..1 CodeableConcept Order of section entries   --></orderedBy>
  <entry><!-- I 0..* Reference(Resource) 
      A reference to data that supports this section --></entry>
  <emptyReason><!-- I 0..1 CodeableConcept Why the section is empty   --></emptyReason>
  <section><!-- See http://hl7.org/fhir/StructureDefinition/Composition#Composition.section  Nested Section --></section>
 </section>
</Composition>

JSON Template

{ // Clinical Document
  // from Element: extension
    "meta" : { Meta }, // IMetadata about the resource
    "implicitRules" : "<uri>", // IA set of rules under which this content was created
    "language" : "<code>", // ILanguage of the resource content
    "text" : { Narrative }, // IText summary of the resource, for human interpretation
    "contained" : [{ Resource }], //Contained, inline Resources
    "extension" : [ //  sliced by value:url  in the specified order, Open 
      { // Version-specific identifier for composition // I
        // from Element: extension
      }
    ],
    "modifierExtension" : [{ Extension }], // IExtensions that cannot be ignored
    "url" : "<uri>", // ICanonical identifier for this Composition, represented as a URI (globally unique)
    "identifier" : [{ Identifier }], // IVersion-independent identifier for the Composition
    "version" : "<string>", // IAn explicitly assigned identifer of a variation of the content in the Composition
    "status" : "<code>", // I R! registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
    "type" : { CodeableConcept }, // I R! Kind of composition (LOINC if possible)
    "category" : [{ CodeableConcept }], // ICategorization of Composition
    "subject" : [{ Reference(Patient) }], // IWho and/or what the composition is about
    "encounter" : { Reference(Encounter) }, // IContext of the Composition
    "date" : "<dateTime>", // I R! Composition editing time
    "useContext" : [{ UsageContext }], // IThe context that the content is intended to support
    "author" : [{ Reference(Practitioner) }], // I R! Who and/or what authored the composition
    "name" : "<string>", // IName for this Composition (computer friendly)
    "title" : "<string>", // I R! Human Readable name/title
    "note" : [{ Annotation }], // IFor any additional notes
    "attester" : [{ BackboneElement }], // IAttests to accuracy of composition
    "custodian" : { Reference(Organization) }, // IOrganization which maintains the composition
    "relatesTo" : [{ RelatedArtifact }], // IRelationships to other compositions/documents
    "event" : [{ BackboneElement }], // IThe clinical service(s) being documented
    "section" : [{ BackboneElement }], // IComposition is broken into sections
  }

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

2.8.15.2.2 Terminology Bindings

Path	Name	Conformance	ValueSet
Composition.language	Common Languages	preferred	Common Languages
Composition.status	CompositionStatus	required	CompositionStatus
Composition.type	FHIR Document Type Codes	preferred	FHIR Document Type Codes
Composition.category	Referenced Item Category Value Set	example	Referenced Item Category Value Set
Composition.attester.mode	CompositionAttestationMode	preferred	CompositionAttestationMode
Composition.event.code	v3 Code System ActCode	example	v3 Code System ActCode
Composition.section.code	Document Section Codes	example	Document Section Codes
Composition.section.mode	ListMode	required	ListMode
Composition.section.orderedBy	List Order Codes	preferred	List Order Codes
Composition.section.emptyReason	List Empty Reasons	preferred	List Empty Reasons