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Structured Documents 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.
Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.
This indicates the differences between this profile and the base Composition structure.
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
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.
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
id | Σ | 0..1 | id | Logical id of this artifact |
meta | Σ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: All Languages (required): IETF language tag for a human language | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
url | Σ | 0..1 | uri | Canonical identifier for this Composition, represented as a URI (globally unique) |
identifier | Σ | 0..* | Identifier | Version-independent identifier for the Composition |
version | Σ | 0..1 | string | An explicitly assigned identifer of a variation of the content in the Composition |
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: Composition Status (required): The workflow/clinical status of the composition. |
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIR Document Type Codes (preferred): Type of a composition. |
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: Referenced Item Category Value Set (example): High-level kind of a clinical document at a macro level. |
subject | Σ | 0..* | Reference(Patient | Practitioner | Group | Device | Location) | Who and/or what the composition is about |
encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition |
date | Σ | 1..1 | dateTime | Composition editing time |
useContext | Σ | 0..* | UsageContext | The context that the content is intended to support |
author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
name | Σ | 0..1 | string | Name for this Composition (computer friendly) |
title | Σ | 1..1 | string | Human Readable name/title |
note | 0..* | Annotation | For any additional notes | |
attester | 0..* | BackboneElement | Attests to accuracy of composition | |
id | 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: Composition Attestation Mode (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 | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition |
relatesTo | 0..* | RelatedArtifact | Relationships to other compositions/documents | |
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented |
id | 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 |
period | Σ | 0..1 | Period | The period covered by the documentation |
detail | Σ | 0..* | CodeableReference(Resource) | The event(s) being documented, as code(s), reference(s), or both Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
section | C | 0..* | BackboneElement | Composition is broken into sections |
id | 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..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | 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 | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred): What order applies to the items in the entry. | |
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | C | 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 |
<!-- ClinicalDocument --> <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> <period><!-- I 0..1 Period The period covered by the documentation --></period> <detail><!-- I 0..* CodeableReference The event(s) being documented, as code(s), reference(s), or both --></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> <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>
{ // ClinicalDocument // 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 "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.
Differential View
This indicates the differences between this profile and the base Composition structure.
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
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.
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
id | Σ | 0..1 | id | Logical id of this artifact |
meta | Σ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: All Languages (required): IETF language tag for a human language | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
url | Σ | 0..1 | uri | Canonical identifier for this Composition, represented as a URI (globally unique) |
identifier | Σ | 0..* | Identifier | Version-independent identifier for the Composition |
version | Σ | 0..1 | string | An explicitly assigned identifer of a variation of the content in the Composition |
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: Composition Status (required): The workflow/clinical status of the composition. |
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIR Document Type Codes (preferred): Type of a composition. |
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: Referenced Item Category Value Set (example): High-level kind of a clinical document at a macro level. |
subject | Σ | 0..* | Reference(Patient | Practitioner | Group | Device | Location) | Who and/or what the composition is about |
encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition |
date | Σ | 1..1 | dateTime | Composition editing time |
useContext | Σ | 0..* | UsageContext | The context that the content is intended to support |
author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
name | Σ | 0..1 | string | Name for this Composition (computer friendly) |
title | Σ | 1..1 | string | Human Readable name/title |
note | 0..* | Annotation | For any additional notes | |
attester | 0..* | BackboneElement | Attests to accuracy of composition | |
id | 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: Composition Attestation Mode (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 | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition |
relatesTo | 0..* | RelatedArtifact | Relationships to other compositions/documents | |
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented |
id | 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 |
period | Σ | 0..1 | Period | The period covered by the documentation |
detail | Σ | 0..* | CodeableReference(Resource) | The event(s) being documented, as code(s), reference(s), or both Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. |
section | C | 0..* | BackboneElement | Composition is broken into sections |
id | 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..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | 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 | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred): What order applies to the items in the entry. | |
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | C | 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
<!-- ClinicalDocument --> <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> <period><!-- I 0..1 Period The period covered by the documentation --></period> <detail><!-- I 0..* CodeableReference The event(s) being documented, as code(s), reference(s), or both --></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> <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
{ // ClinicalDocument // 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 "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
Path | Name | Conformance | ValueSet |
Composition.language | All Languages | required | All Languages |
Composition.status | Composition Status | required | Composition Status |
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 | Composition Attestation Mode | preferred | Composition Attestation Mode |
Composition.event.detail | v3 Code System ActCode | example | v3 Code System ActCode |
Composition.section.code | Document Section Codes | example | Document Section Codes |
Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |