This page is part of the FHIR Specification (v0.0.82: DSTU 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

StructureDefinition: ClinicalDocument

The official URL for this profile is: 

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

Standard Profile for CDA R2 on FHIR

This profile was published on Sun, Nov 16, 2014 00:00+1100 with unknown status 'preliminary" by .

Formal Views of Profile Content

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

This structure is derived from Composition.

This structure is derived from Composition.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 1..1
... language 0..1code
... identifier 0..1IdentifierClinical Document setId
... date 1..1dateTimeCDA document date/time
... type 1..1CodeableConceptDocument Type
... class 0..0CodeableConcept
... title 0..1stringClinical Document Title
... status 1..1codefinal
Fixed Value: final
... confidentiality ?!1..1codeDocument Confidentiality
... subject 1..1#PatientRoleCDA RecordTarget
... author 1..*Practitioner, Device, Patient, RelatedPersonWho and/or what authored the composition
... attester 0..*Attests to accuracy of composition
.... mode 1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time 0..1dateTimeWhen composition attested
.... party 0..1Patient, Practitioner, OrganizationWho attested the composition
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... custodian 0..1OrganizationOrg which maintains the composition
... event 0..1The clinical event/act/item being documented
.... code 0..*CodeableConceptCode(s) that apply to the event being documented
Binding: DocumentEventType (required)
.... period 0..1PeriodThe period covered by the documentation
.... detail 0..*AnyFull details for the event(s) the composition consents
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... encounter 0..1EncounterContext of the conposition
... section I0..*Composition is broken into sections
2: A section SHALL have content or one or more sections, but not both.
.... title 0..1stringLabel for section
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: CompositionSectionType (required)
.... subject ?!0..1Patient, Group, DeviceIf section different to composition
.... content 0..1AnyThe actual data for the section
.... section 0..*Nested Section
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... cda-inFulFillmentOf 0..*#inFulFillmentOfDiagnosticOrderCDA inFulFillmentOf
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 1..1CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... meta 0..1MetaMetadata about the resource
... implicitRules ?!0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Language (required)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierClinical Document setId
... date Σ1..1dateTimeCDA document date/time
... type Σ1..1CodeableConceptDocument Type
Binding: DocumentType (required)
... title Σ0..1stringClinical Document Title
... status ?! Σ1..1codefinal
Binding: CompositionStatus (required)
Fixed Value: final
... confidentiality ?! Σ1..1codeDocument Confidentiality
Binding: DocumentConfidentiality (required)
... subject Σ1..1#PatientRoleCDA RecordTarget
... author Σ1..*Practitioner, Device, Patient, RelatedPersonWho and/or what authored the composition
... attester Σ0..*Attests to accuracy of composition
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time Σ0..1dateTimeWhen composition attested
.... party Σ0..1Patient, Practitioner, OrganizationWho attested the composition
... custodian Σ0..1OrganizationOrg which maintains the composition
... event Σ0..1The clinical event/act/item being documented
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: DocumentEventType (required)
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*AnyFull details for the event(s) the composition consents
... encounter Σ0..1EncounterContext of the conposition
... section I0..*Composition is broken into sections
cmp-1: A section must have either subsections or content
2: A section SHALL have content or one or more sections, but not both.
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... title 0..1stringLabel for section
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: CompositionSectionType (required)
.... content I0..1AnyThe actual data for the section
.... section I0..*Nested Section

todo

This structure is derived from Composition.

Differential View

This structure is derived from Composition.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 1..1
... language 0..1code
... identifier 0..1IdentifierClinical Document setId
... date 1..1dateTimeCDA document date/time
... type 1..1CodeableConceptDocument Type
... class 0..0CodeableConcept
... title 0..1stringClinical Document Title
... status 1..1codefinal
Fixed Value: final
... confidentiality ?!1..1codeDocument Confidentiality
... subject 1..1#PatientRoleCDA RecordTarget
... author 1..*Practitioner, Device, Patient, RelatedPersonWho and/or what authored the composition
... attester 0..*Attests to accuracy of composition
.... mode 1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time 0..1dateTimeWhen composition attested
.... party 0..1Patient, Practitioner, OrganizationWho attested the composition
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... custodian 0..1OrganizationOrg which maintains the composition
... event 0..1The clinical event/act/item being documented
.... code 0..*CodeableConceptCode(s) that apply to the event being documented
Binding: DocumentEventType (required)
.... period 0..1PeriodThe period covered by the documentation
.... detail 0..*AnyFull details for the event(s) the composition consents
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... encounter 0..1EncounterContext of the conposition
... section I0..*Composition is broken into sections
2: A section SHALL have content or one or more sections, but not both.
.... title 0..1stringLabel for section
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: CompositionSectionType (required)
.... subject ?!0..1Patient, Group, DeviceIf section different to composition
.... content 0..1AnyThe actual data for the section
.... section 0..*Nested Section
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... cda-inFulFillmentOf 0..*#inFulFillmentOfDiagnosticOrderCDA inFulFillmentOf

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 1..1CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... meta 0..1MetaMetadata about the resource
... implicitRules ?!0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Language (required)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierClinical Document setId
... date Σ1..1dateTimeCDA document date/time
... type Σ1..1CodeableConceptDocument Type
Binding: DocumentType (required)
... title Σ0..1stringClinical Document Title
... status ?! Σ1..1codefinal
Binding: CompositionStatus (required)
Fixed Value: final
... confidentiality ?! Σ1..1codeDocument Confidentiality
Binding: DocumentConfidentiality (required)
... subject Σ1..1#PatientRoleCDA RecordTarget
... author Σ1..*Practitioner, Device, Patient, RelatedPersonWho and/or what authored the composition
... attester Σ0..*Attests to accuracy of composition
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... mode Σ1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time Σ0..1dateTimeWhen composition attested
.... party Σ0..1Patient, Practitioner, OrganizationWho attested the composition
... custodian Σ0..1OrganizationOrg which maintains the composition
... event Σ0..1The clinical event/act/item being documented
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: DocumentEventType (required)
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*AnyFull details for the event(s) the composition consents
... encounter Σ0..1EncounterContext of the conposition
... section I0..*Composition is broken into sections
cmp-1: A section must have either subsections or content
2: A section SHALL have content or one or more sections, but not both.
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... title 0..1stringLabel for section
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: CompositionSectionType (required)
.... content I0..1AnyThe actual data for the section
.... section I0..*Nested Section

XML Template

JSON Template

todo

 

Other representations of profile: (todo)

Terminology Bindings

PathNameConformanceValueSet
Composition.languageLanguagerequiredhttp://tools.ietf.org/html/bcp47
Composition.typeDocumentTyperequiredFHIR Document Type Codes
Composition.classDocumentC80ClasspreferredDocument Class Value Set
Composition.statusCompositionStatusrequiredCompositionStatus
Composition.confidentialityDocumentConfidentialityrequiredv3 Code System Confidentiality
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
Composition.event.codeDocumentEventTyperequiredv3 Code System ActCode
Composition.section.codeCompositionSectionTyperequiredDocument Section Codes

Constraints

IdPathNameDetails
cmp-1Composition.sectionSection ContentA section must have either subsections or content
XPath: (exists(f:content) and not(exists(f:section))) or (exists(f:section) and not(exists(f:content)))
2Composition.sectionSection RuleA section SHALL have content or one or more sections, but not both.
XPath: exists(f:content) != exists(f:section)
.