This page is part of the Bidirectional Services eReferrals (BSeR) (v1.0.0: STU 1) based on FHIR R4. This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
Definitions for the BSeR-ReferralRequestComposition Profile.
1. Composition | |
Definition | A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). |
Control | 0..* |
Comments | While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical. |
Invariants | Defined on this element dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty()) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (: contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (: text.`div`.exists()) |
2. Composition.id | |
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. |
Control | 0..1 |
Type | string |
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
3. Composition.meta | |
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. |
Control | 0..1 |
Type | Meta |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
4. Composition.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
Control | 0..1 |
Type | uri |
Is Modifier | true |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
5. Composition.language | |
Definition | The base language in which the resource is written. |
Control | 0..1 |
Binding | A human language. The codes SHOULD be taken from CommonLanguages Max Binding: AllLanguages |
Type | code |
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
6. Composition.text | |
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. |
Control | 0..1 |
Type | Narrative |
Alternate Names | narrative, html, xhtml, display |
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
7. Composition.contained | |
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. |
Control | 0..* |
Type | Resource |
Alternate Names | inline resources, anonymous resources, contained resources |
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. |
8. Composition.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
9. Composition.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
10. Composition.identifier | |
Definition | A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time. |
Note | This is a business identifier, not a resource identifier (see discussion) |
Control | 0..1 |
Type | Identifier |
Comments | Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
11. Composition.status | |
Definition | The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. |
Control | 1..1 |
Binding | The workflow/clinical status of the composition. The codes SHALL be taken from CompositionStatus |
Type | code |
Is Modifier | true |
Requirements | Need to be able to mark interim, amended, or withdrawn compositions or documents. |
Comments | If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
12. Composition.type | |
Definition | Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. |
Control | 1..1 |
Binding | Type of a composition. The codes SHOULD be taken from FHIRDocumentTypeCodes |
Type | CodeableConcept |
Requirements | Key metadata element describing the composition, used in searching/filtering. |
Comments | For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
13. Composition.category | |
Definition | A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type. |
Control | 0..* |
Binding | High-level kind of a clinical document at a macro level. For example codes, see DocumentClassValueSet |
Type | CodeableConcept |
Requirements | Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. |
Comments | This is a metadata field from XDS/MHD. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
14. Composition.subject | |
Definition | Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). |
Control | 1..1 |
Type | Reference(USCorePatientProfile) |
Requirements | Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. |
Comments | For clinical documents, this is usually the patient. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
15. Composition.encounter | |
Definition | Describes the clinical encounter or type of care this documentation is associated with. |
Control | 0..1 |
Type | Reference(Encounter) |
Requirements | Provides context for the composition and supports searching. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
16. Composition.date | |
Definition | The composition editing time, when the composition was last logically changed by the author. |
Control | 1..1 |
Type | dateTime |
Requirements | dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. |
Comments | The Last Modified Date on the composition may be after the date of the document was attested without being changed. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
17. Composition.author | |
Definition | Identifies who is responsible for the information in the composition, not necessarily who typed it in. |
Control | 1..1 |
Type | Reference(BSeR_ReferralInitiatorPractitionerRole) |
Requirements | Identifies who is responsible for the content. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
18. Composition.title | |
Definition | Official human-readable label for the composition. |
Control | 1..1 |
Type | string |
Comments | For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
19. Composition.confidentiality | |
Definition | The code specifying the level of confidentiality of the Composition. |
Control | 0..1 |
Binding | Codes specifying the level of confidentiality of the composition. The codes SHALL be taken from v3.ConfidentialityClassification (2014-03-26) |
Type | code |
Comments | The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
20. Composition.attester | |
Definition | A participant who has attested to the accuracy of the composition/document. |
Control | 0..* |
Type | BackboneElement |
Requirements | Identifies responsibility for the accuracy of the composition content. |
Comments | Only list each attester once. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
21. Composition.attester.id | |
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Control | 0..1 |
Type | string |
22. Composition.attester.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
23. Composition.attester.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
24. Composition.attester.mode | |
Definition | The type of attestation the authenticator offers. |
Control | 1..1 |
Binding | The way in which a person authenticated a composition. The codes SHALL be taken from CompositionAttestationMode |
Type | code |
Requirements | Indicates the level of authority of the attestation. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
25. Composition.attester.time | |
Definition | When the composition was attested by the party. |
Control | 0..1 |
Type | dateTime |
Requirements | Identifies when the information in the composition was deemed accurate. (Things may have changed since then.). |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
26. Composition.attester.party | |
Definition | Who attested the composition in the specified way. |
Control | 0..1 |
Type | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) |
Requirements | Identifies who has taken on the responsibility for accuracy of the composition content. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
27. Composition.custodian | |
Definition | Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. |
Control | 0..1 |
Type | Reference(Organization) |
Requirements | Identifies where to go to find the current version, where to report issues, etc. |
Comments | This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
28. Composition.relatesTo | |
Definition | Relationships that this composition has with other compositions or documents that already exist. |
Control | 0..* |
Type | BackboneElement |
Comments | A document is a version specific composition. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
29. Composition.relatesTo.id | |
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Control | 0..1 |
Type | string |
30. Composition.relatesTo.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
31. Composition.relatesTo.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
32. Composition.relatesTo.code | |
Definition | The type of relationship that this composition has with anther composition or document. |
Control | 1..1 |
Binding | The type of relationship between documents. The codes SHALL be taken from DocumentRelationshipType |
Type | code |
Comments | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
33. Composition.relatesTo.target[x] | |
Definition | The target composition/document of this relationship. |
Control | 1..1 |
Type | Choice of: Identifier, Reference(Composition) |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
34. Composition.event | |
Definition | The clinical service, such as a colonoscopy or an appendectomy, being documented. |
Control | 0..* |
Type | BackboneElement |
Requirements | Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. |
Comments | The event needs to be consistent with the type element, though can provide further information if desired. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
35. Composition.event.id | |
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Control | 0..1 |
Type | string |
36. Composition.event.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
37. Composition.event.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
38. Composition.event.code | |
Definition | This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. |
Control | 0..* |
Binding | This list of codes represents the main clinical acts being documented. For example codes, see v3 Code System ActCode |
Type | CodeableConcept |
Comments | An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
39. Composition.event.period | |
Definition | The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. |
Control | 0..1 |
Type | Period |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
40. Composition.event.detail | |
Definition | The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. |
Control | 0..* |
Type | Reference(Resource) |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
41. Composition.section | |
Definition | The root of the sections that make up the composition. |
Control | 1..* |
Type | BackboneElement |
Invariants | Defined on this element cmp-1: A section must contain at least one of text, entries, or sub-sections (: text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (: emptyReason.empty() or entry.empty()) ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on Composition.section. The slices are unordered and Open, and can be differentiated using the following discriminators:
|
42. Composition.section.id | |
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Control | 0..1 |
Type | string |
43. Composition.section.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
44. Composition.section.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
45. Composition.section.title | |
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. |
Control | 0..1 |
Type | string |
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. |
Alternate Names | header, label, caption |
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
46. Composition.section.code | |
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title. |
Control | 0..1 |
Binding | Classification of a section of a composition/document. For example codes, see DocumentSectionCodes |
Type | CodeableConcept |
Requirements | Provides computable standardized labels to topics within the document. |
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
47. Composition.section.author | |
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. |
Control | 0..* |
Type | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) |
Requirements | Identifies who is responsible for the content. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
48. Composition.section.focus | |
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). |
Control | 0..1 |
Type | Reference(Resource) |
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
49. Composition.section.text | |
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
Control | 0..1 This element is affected by the following invariants: cmp-1 |
Type | Narrative |
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
50. Composition.section.mode | |
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. |
Control | 0..1 |
Binding | The processing mode that applies to this section. The codes SHALL be taken from ListMode |
Type | code |
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. |
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
51. Composition.section.orderedBy | |
Definition | Specifies the order applied to the items in the section entries. |
Control | 0..1 |
Binding | What order applies to the items in the entry. The codes SHOULD be taken from ListOrderCodes |
Type | CodeableConcept |
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. |
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
52. Composition.section.entry | |
Definition | A reference to the actual resource from which the narrative in the section is derived. |
Control | 0..* This element is affected by the following invariants: cmp-2 |
Type | Reference(Resource) |
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
53. Composition.section.emptyReason | |
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. |
Control | 0..1 This element is affected by the following invariants: cmp-2 |
Binding | If a section is empty, why it is empty. The codes SHOULD be taken from ListEmptyReasons |
Type | CodeableConcept |
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. |
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
54. Composition.section.section | |
Definition | A nested sub-section within this section. |
Control | 0..* This element is affected by the following invariants: cmp-1 |
Type | See Composition.section |
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
55. Composition.section:referralServiceRequestSupportingInformation | |
SliceName | referralServiceRequestSupportingInformation |
Definition | The root of the sections that make up the composition. |
Control | 0..1 |
Type | BackboneElement |
Invariants | Defined on this element cmp-1: A section must contain at least one of text, entries, or sub-sections (: text.exists() or entry.exists() or section.exists()) cmp-2: A section can only have an emptyReason if it is empty (: emptyReason.empty() or entry.empty()) ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
56. Composition.section:referralServiceRequestSupportingInformation.id | |
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Control | 0..1 |
Type | string |
57. Composition.section:referralServiceRequestSupportingInformation.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
58. Composition.section:referralServiceRequestSupportingInformation.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
59. Composition.section:referralServiceRequestSupportingInformation.title | |
Definition | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. |
Control | 0..1 |
Type | string |
Requirements | Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. |
Alternate Names | header, label, caption |
Comments | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
60. Composition.section:referralServiceRequestSupportingInformation.code | |
Definition | A code identifying the kind of content contained within the section. This must be consistent with the section title. |
Control | 1..1 |
Binding | Classification of a section of a composition/document. For example codes, see DocumentSectionCodes |
Type | CodeableConcept |
Requirements | Provides computable standardized labels to topics within the document. |
Comments | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
Fixed Value | <valueCodeableConcept xmlns="http://hl7.org/fhir"> <coding> <system value="http://hl7.org/fhir/us/bser/CodeSystem/bser"/> <code value="RSRSI"/> <display value="CompositionSectionReferralServiceRequestSupportingInformation"/> </coding> </valueCodeableConcept> |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
61. Composition.section:referralServiceRequestSupportingInformation.author | |
Definition | Identifies who is responsible for the information in this section, not necessarily who typed it in. |
Control | 0..* |
Type | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) |
Requirements | Identifies who is responsible for the content. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
62. Composition.section:referralServiceRequestSupportingInformation.focus | |
Definition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). |
Control | 0..1 |
Type | Reference(Resource) |
Comments | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
63. Composition.section:referralServiceRequestSupportingInformation.text | |
Definition | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. |
Control | 0..1 This element is affected by the following invariants: cmp-1 |
Type | Narrative |
Comments | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
64. Composition.section:referralServiceRequestSupportingInformation.mode | |
Definition | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. |
Control | 0..1 |
Binding | The processing mode that applies to this section. The codes SHALL be taken from ListMode |
Type | code |
Requirements | Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. |
Comments | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
65. Composition.section:referralServiceRequestSupportingInformation.orderedBy | |
Definition | Specifies the order applied to the items in the section entries. |
Control | 0..1 |
Binding | What order applies to the items in the entry. The codes SHOULD be taken from ListOrderCodes |
Type | CodeableConcept |
Requirements | Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. |
Comments | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
66. Composition.section:referralServiceRequestSupportingInformation.entry | |
Definition | A reference to the actual resource from which the narrative in the section is derived. |
Control | 0..1 This element is affected by the following invariants: cmp-2 |
Type | Reference(Resource) |
Must Support | true |
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on Composition.section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators:
|
67. Composition.section:referralServiceRequestSupportingInformation.entry:ObesityReferralSupportingInformation | |
SliceName | ObesityReferralSupportingInformation |
Definition | A reference to the actual resource from which the narrative in the section is derived. |
Control | 0..1 This element is affected by the following invariants: cmp-2 |
Type | Reference(BSeR_ObesityReferralSupportingInformation) |
Must Support | true |
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
68. Composition.section:referralServiceRequestSupportingInformation.entry:ArthritisReferralSupportingInformation | |
SliceName | ArthritisReferralSupportingInformation |
Definition | A reference to the actual resource from which the narrative in the section is derived. |
Control | 0..1 This element is affected by the following invariants: cmp-2 |
Type | Reference(BSeR_ArthritisReferralSupportingInformation) |
Must Support | true |
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
69. Composition.section:referralServiceRequestSupportingInformation.entry:HypertensionReferralSupportingInformation | |
SliceName | HypertensionReferralSupportingInformation |
Definition | A reference to the actual resource from which the narrative in the section is derived. |
Control | 0..1 This element is affected by the following invariants: cmp-2 |
Type | Reference(BSeR_HypertensionReferralSupportingInformation) |
Must Support | true |
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
70. Composition.section:referralServiceRequestSupportingInformation.entry:EarlyChildhoodNutritionReferralSupportingInformation | |
SliceName | EarlyChildhoodNutritionReferralSupportingInformation |
Definition | A reference to the actual resource from which the narrative in the section is derived. |
Control | 0..1 This element is affected by the following invariants: cmp-2 |
Type | Reference(BSeR_EarlyChildhoodNutritionReferralSupportingInformation) |
Must Support | true |
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
71. Composition.section:referralServiceRequestSupportingInformation.entry:DiabetesPreventionReferralSupportingInformation | |
SliceName | DiabetesPreventionReferralSupportingInformation |
Definition | A reference to the actual resource from which the narrative in the section is derived. |
Control | 0..1 This element is affected by the following invariants: cmp-2 |
Type | Reference(BSeR_DiabetesPreventionReferralSupportingInformation) |
Must Support | true |
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
72. Composition.section:referralServiceRequestSupportingInformation.entry:TobaccoUseCessationReferralSupportingInformation | |
SliceName | TobaccoUseCessationReferralSupportingInformation |
Definition | A reference to the actual resource from which the narrative in the section is derived. |
Control | 0..1 This element is affected by the following invariants: cmp-2 |
Type | Reference(BSeR_TobaccoUseCessationReferralSupportingInformation) |
Must Support | true |
Comments | If there are no entries in the list, an emptyReason SHOULD be provided. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
73. Composition.section:referralServiceRequestSupportingInformation.emptyReason | |
Definition | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. |
Control | 0..1 This element is affected by the following invariants: cmp-2 |
Binding | If a section is empty, why it is empty. The codes SHOULD be taken from ListEmptyReasons |
Type | CodeableConcept |
Requirements | Allows capturing things like "none exist" or "not asked" which can be important for most lists. |
Comments | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
74. Composition.section:referralServiceRequestSupportingInformation.section | |
Definition | A nested sub-section within this section. |
Control | 0..* This element is affected by the following invariants: cmp-1 |
Type | See Composition.section:referralServiceRequestSupportingInformation |
Comments | Nested sections are primarily used to help human readers navigate to particular portions of the document. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |