This page is part of the FHIR Specification (v4.0.1: R4 - Mixed Normative and STU) in it's permanent home (it will always be available at this URL). 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 R4 R3 R2
Structured Documents Work Group | Maturity Level: 1 | Trial Use | Use Context: Any |
The official 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 Tue, Mar 17, 2015 00:00+1100 as a draft by Health Level Seven, Inc. - Structured Documents WG.
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.
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | |||
composition-clinicaldocument-versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
subject | 0..1 | Reference(Patient | Practitioner | Group | Device | Location) | ||
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation | |
id | Σ | 0..1 | string | Logical id of this artifact |
meta | ΣI | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
language | I | 0..1 | code | Language of the resource content Binding: Common Languages (preferred) Max Binding: All Languages |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
extension | I | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
composition-clinicaldocument-versionNumber | I | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber |
modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
identifier | ΣI | 0..1 | Identifier | Version-independent identifier for the Composition |
status | ?!ΣI | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required) |
type | ΣI | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIR Document Type Codes (preferred) |
category | ΣI | 0..* | CodeableConcept | Categorization of Composition Binding: Document Class Value Set (example) |
subject | ΣI | 0..1 | Reference(Patient | Practitioner | Group | Device | Location) | Who and/or what the composition is about |
encounter | ΣI | 0..1 | Reference(Encounter) | Context of the Composition |
date | ΣI | 1..1 | dateTime | Composition editing time |
author | ΣI | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
title | ΣI | 1..1 | string | Human Readable name/title |
confidentiality | ΣI | 0..1 | code | As defined by affinity domain Binding: ConfidentialityClassification (required) |
attester | I | 0..* | BackboneElement | Attests to accuracy of composition |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | I | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
mode | I | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required) |
time | I | 0..1 | dateTime | When the composition was attested |
party | I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
custodian | ΣI | 0..1 | Reference(Organization) | Organization which maintains the composition |
relatesTo | I | 0..* | BackboneElement | Relationships to other compositions/documents |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | I | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | I | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required) |
target[x] | I | 1..1 | Target of the relationship | |
targetIdentifier | Identifier | |||
targetReference | Reference(composition.html) | |||
event | ΣI | 0..* | BackboneElement | The clinical service(s) being documented |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | I | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | ΣI | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: ActCode (example) |
period | ΣI | 0..1 | Period | The period covered by the documentation |
detail | ΣI | 0..* | Reference(Resource) | The event(s) being documented |
section | I | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | I | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | I | 0..1 | string | Label for section (e.g. for ToC) |
code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Document Section Codes (example) |
author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section Nested Section | |
Documentation for this format |
<!-- Clinical Document --> <Composition xmlns="http://hl7.org/fhir" > <!-- from Element: extension --> <id><!-- 0..1 string Logical id of this artifact --></id> <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 Kind of composition (LOINC if possible) --></type> <category><!-- 0..* CodeableConcept Categorization of Composition --></category> <subject><!-- 0..1 Reference(Patient) Who and/or what the composition is about --></subject> <encounter><!-- 0..1 Reference(Encounter) Context of the Composition --></encounter> <date value="[dateTime]"/><!-- 1..1 Composition editing time --> <author><!-- 1..* Reference(Practitioner) Who and/or what authored the composition --></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(Patient) Who attested the composition --></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..* BackboneElement <!-- 0..* The clinical service(s) being documented --> <modifierExtension><!-- 0..* Extension Extensions that cannot be ignored even if unrecognized --></modifierExtension> <code><!-- 0..* CodeableConcept Code(s) that apply to the event being documented --></code> <period><!-- 0..1 Period The period covered by the documentation --></period> <detail><!-- 0..* Reference(Resource) The event(s) being documented --></detail> </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>
{ // Clinical Document // 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 "extension" : [ // sliced by value:url in the specified order, Open { // Version-specific identifier for composition // C? // from Element: extension } ], "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! Kind of composition (LOINC if possible) "category" : [{ CodeableConcept }], // C?Categorization of Composition "subject" : { Reference(Patient) }, // C?Who and/or what the composition is about "encounter" : { Reference(Encounter) }, // C?Context of the Composition "date" : "<dateTime>", // C? R! Composition editing time "author" : [{ Reference(Practitioner) }], // C? R! Who and/or what authored the composition "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 "event" : [{ BackboneElement }], // C?The clinical service(s) being documented "section" : [{ BackboneElement }], // C?Composition is broken into sections }
This structure is derived from Composition.
Differential View
This structure is derived from Composition.
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | |||
composition-clinicaldocument-versionNumber | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber | |
subject | 0..1 | Reference(Patient | Practitioner | Group | Device | Location) | ||
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation | |
id | Σ | 0..1 | string | Logical id of this artifact |
meta | ΣI | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
language | I | 0..1 | code | Language of the resource content Binding: Common Languages (preferred) Max Binding: All Languages |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
extension | I | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
composition-clinicaldocument-versionNumber | I | 0..* | string | Version-specific identifier for composition URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber |
modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
identifier | ΣI | 0..1 | Identifier | Version-independent identifier for the Composition |
status | ?!ΣI | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required) |
type | ΣI | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIR Document Type Codes (preferred) |
category | ΣI | 0..* | CodeableConcept | Categorization of Composition Binding: Document Class Value Set (example) |
subject | ΣI | 0..1 | Reference(Patient | Practitioner | Group | Device | Location) | Who and/or what the composition is about |
encounter | ΣI | 0..1 | Reference(Encounter) | Context of the Composition |
date | ΣI | 1..1 | dateTime | Composition editing time |
author | ΣI | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
title | ΣI | 1..1 | string | Human Readable name/title |
confidentiality | ΣI | 0..1 | code | As defined by affinity domain Binding: ConfidentialityClassification (required) |
attester | I | 0..* | BackboneElement | Attests to accuracy of composition |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | I | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
mode | I | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required) |
time | I | 0..1 | dateTime | When the composition was attested |
party | I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition |
custodian | ΣI | 0..1 | Reference(Organization) | Organization which maintains the composition |
relatesTo | I | 0..* | BackboneElement | Relationships to other compositions/documents |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | I | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | I | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required) |
target[x] | I | 1..1 | Target of the relationship | |
targetIdentifier | Identifier | |||
targetReference | Reference(composition.html) | |||
event | ΣI | 0..* | BackboneElement | The clinical service(s) being documented |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | I | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | ΣI | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: ActCode (example) |
period | ΣI | 0..1 | Period | The period covered by the documentation |
detail | ΣI | 0..* | Reference(Resource) | The event(s) being documented |
section | I | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | I | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
title | I | 0..1 | string | Label for section (e.g. for ToC) |
code | I | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Document Section Codes (example) |
author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section |
focus | I | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition |
text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
mode | I | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
orderedBy | I | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) |
entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
section | I | 0..* | Unknown reference to #Composition.section Nested Section | |
Documentation for this format |
XML Template
<!-- Clinical Document --> <Composition xmlns="http://hl7.org/fhir" > <!-- from Element: extension --> <id><!-- 0..1 string Logical id of this artifact --></id> <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 Kind of composition (LOINC if possible) --></type> <category><!-- 0..* CodeableConcept Categorization of Composition --></category> <subject><!-- 0..1 Reference(Patient) Who and/or what the composition is about --></subject> <encounter><!-- 0..1 Reference(Encounter) Context of the Composition --></encounter> <date value="[dateTime]"/><!-- 1..1 Composition editing time --> <author><!-- 1..* Reference(Practitioner) Who and/or what authored the composition --></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(Patient) Who attested the composition --></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..* BackboneElement <!-- 0..* The clinical service(s) being documented --> <modifierExtension><!-- 0..* Extension Extensions that cannot be ignored even if unrecognized --></modifierExtension> <code><!-- 0..* CodeableConcept Code(s) that apply to the event being documented --></code> <period><!-- 0..1 Period The period covered by the documentation --></period> <detail><!-- 0..* Reference(Resource) The event(s) being documented --></detail> </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
{ // Clinical Document // 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 "extension" : [ // sliced by value:url in the specified order, Open { // Version-specific identifier for composition // C? // from Element: extension } ], "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! Kind of composition (LOINC if possible) "category" : [{ CodeableConcept }], // C?Categorization of Composition "subject" : { Reference(Patient) }, // C?Who and/or what the composition is about "encounter" : { Reference(Encounter) }, // C?Context of the Composition "date" : "<dateTime>", // C? R! Composition editing time "author" : [{ Reference(Practitioner) }], // C? R! Who and/or what authored the composition "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 "event" : [{ BackboneElement }], // C?The clinical service(s) being documented "section" : [{ BackboneElement }], // C?Composition is broken into sections }
Alternate definitions: Master Definition (XML, JSON), Schematron
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 | Document Class Value Set | example | Document Class Value Set |
Composition.confidentiality | V3 Value SetConfidentialityClassification | required | V3 Value SetConfidentialityClassification |
Composition.attester.mode | CompositionAttestationMode | required | CompositionAttestationMode |
Composition.relatesTo.code | DocumentRelationshipType | required | DocumentRelationshipType |
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 |
Id | Path | Details | Requirements |
cmp-1 | Composition.section | A section must contain at least one of text, entries, or sub-sections Expression : text.exists() or entry.exists() or section.exists() | |
cmp-2 | Composition.section | A section can only have an emptyReason if it is empty Expression : emptyReason.empty() or entry.empty() |