Cancer Pathology Data Sharing
2.0.0 - STU 2 United States of America flag

This page is part of the Sharing eCC Data from Pathology Labs to EHR (v2.0.0: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: US Pathology Composition Laboratory Report

Official URL: http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/us-pathology-composition Version: 2.0.0
Standards status: Trial-use Maturity Level: 2 Computable Name: USPathologyComposition

This Composition profile represents a Laboratory Report for the Clinical Pathology Data Sharing Implementation Guide.

Introduction

This US Pathology Composition profile defines how to structure pathology reports based on CAP electronic Cancer Protocols (eCPs) within FHIR.

Key Elements and Binding Requirements

  • extension:diagnosticReportReference:
    • DiagnosticReport is bound to both the Observations AND the Composition through this extension
  • type:
    • Bound to the CAP eCP Form Codes ValueSet
    • Allows unique identification of the specific CAP Protocol
  • section.code:

  • Bound to the CAP eCP Section Codes ValueSet

  • section.entry:
    • Each entry references a section in the report

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition Composition
... text 0..1 Narrative Narrative text
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:diagnosticReport-reference 0..1 (Complex) Extension
URL: http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/composition-diagnosticReportReference
..... value[x] 1..1 Reference(US Pathology Diagnostic Report) Value of extension
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
... identifier 0..1 Identifier Report identifier
... type 1..1 CodeableConcept CAP Form Identifier
Binding: CAP eCP Form Codes (extensible)
... subject 1..1 Reference(US Core Patient Profile) Who and/or what the composition is about
... encounter 0..1 Reference(US Core Encounter Profile) The healthcare event which this Report is about (when test ordered).
... author 1..* Reference(US Pathology Related Practitioner Role) Who and/or what authored the Report
... title 1..1 string CAP Form Title
... attester 0..* BackboneElement Attests the report accuracy
... event
.... code 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: ActCode (3.0.0) (required)
... section S 1..* BackboneElement Composition is broken into sections
.... title 0..1 string Title should be the display of the section code
.... code 0..1 CodeableConcept CAP Form Section Identifier
Binding: CAP eCP Section Codes (extensible)
.... entry 1..* Reference(US Pathology Observation) An Observation representing this section in the report and containing (hasMember) Observations representing the question/answers in the section.

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Composition.type Base extensible CAP eCP Form Codes 📦2.0.0 This IG
Composition.event.code Base required v3 Code System ActCode 📍3.0.0 THO v6.5
Composition.section.​code Base extensible CAP eCP Section Codes 📦2.0.0 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:diagnosticReport-reference 0..1 (Complex) Extension
URL: http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/composition-diagnosticReportReference
..... extension 0..0
..... url 1..1 uri "http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/composition-diagnosticReportReference"
..... value[x] 1..1 Reference(US Pathology Diagnostic Report) Value of extension
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... identifier Σ 0..1 Identifier Report identifier
... status ?!Σ 1..1 code Status of the Report
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type Σ 1..1 CodeableConcept CAP Form Identifier
Binding: CAP eCP Form Codes (extensible)
... subject Σ 1..1 Reference(US Core Patient Profile) Who and/or what the composition is about
... encounter Σ 0..1 Reference(US Core Encounter Profile) The healthcare event which this Report is about (when test ordered).
... date Σ 1..1 dateTime Composition editing time
... author Σ 1..* Reference(US Pathology Related Practitioner Role) Who and/or what authored the Report
... title Σ 1..1 string CAP Form Title
... attester 0..* BackboneElement Attests the report accuracy
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
... section SC 1..* BackboneElement Composition is broken into sections
Constraints: cmp-1, cmp-2
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... title 0..1 string Title should be the display of the section code
.... code 0..1 CodeableConcept CAP Form Section Identifier
Binding: CAP eCP Section Codes (extensible)
.... entry C 1..* Reference(US Pathology Observation) An Observation representing this section in the report and containing (hasMember) Observations representing the question/answers in the section.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base extensible CAP eCP Form Codes 📦2.0.0 This IG
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.section.​code Base extensible CAP eCP Section Codes 📦2.0.0 This IG

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition 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 error Composition 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 error Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... text 0..1 Narrative Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:diagnosticReport-reference 0..1 (Complex) Extension
URL: http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/composition-diagnosticReportReference
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/composition-diagnosticReportReference"
..... value[x] 1..1 Reference(US Pathology Diagnostic Report) Value of extension
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..1 Identifier Report identifier
... status ?!Σ 1..1 code Status of the Report
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type Σ 1..1 CodeableConcept CAP Form Identifier
Binding: CAP eCP Form Codes (extensible)
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject Σ 1..1 Reference(US Core Patient Profile) Who and/or what the composition is about
... encounter Σ 0..1 Reference(US Core Encounter Profile) The healthcare event which this Report is about (when test ordered).
... date Σ 1..1 dateTime Composition editing time
... author Σ 1..* Reference(US Pathology Related Practitioner Role) Who and/or what authored the Report
... title Σ 1..1 string CAP Form Title
... confidentiality Σ 0..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... attester 0..* BackboneElement Attests the report accuracy
.... 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 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): 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..* BackboneElement Relationships to other compositions/documents
.... 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
.... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... 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
.... code Σ 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: ActCode (3.0.0) (required)
.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... section SC 1..* BackboneElement Composition is broken into sections
Constraints: cmp-1, cmp-2
.... 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 Title should be the display of the section code
.... code 0..1 CodeableConcept CAP Form Section Identifier
Binding: CAP eCP Section Codes (extensible)
.... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
.... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
.... entry C 1..* Reference(US Pathology Observation) An Observation representing this section in the report and containing (hasMember) Observations representing the question/answers in the section.
.... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section C 0..* See section (Composition) Nested Section

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Composition.extension:diagnosticReport-reference.​value[x].type Base extensible ResourceType 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base extensible CAP eCP Form Codes 📦2.0.0 This IG
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.event.code Base required v3 Code System ActCode 📍3.0.0 THO v6.5
Composition.section.​code Base extensible CAP eCP Section Codes 📦2.0.0 This IG
Composition.section.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition 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 error Composition 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 error Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition Composition
... text 0..1 Narrative Narrative text
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:diagnosticReport-reference 0..1 (Complex) Extension
URL: http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/composition-diagnosticReportReference
..... value[x] 1..1 Reference(US Pathology Diagnostic Report) Value of extension
...... reference 1..1 string Literal reference, Relative, internal or absolute URL
... identifier 0..1 Identifier Report identifier
... type 1..1 CodeableConcept CAP Form Identifier
Binding: CAP eCP Form Codes (extensible)
... subject 1..1 Reference(US Core Patient Profile) Who and/or what the composition is about
... encounter 0..1 Reference(US Core Encounter Profile) The healthcare event which this Report is about (when test ordered).
... author 1..* Reference(US Pathology Related Practitioner Role) Who and/or what authored the Report
... title 1..1 string CAP Form Title
... attester 0..* BackboneElement Attests the report accuracy
... event
.... code 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: ActCode (3.0.0) (required)
... section S 1..* BackboneElement Composition is broken into sections
.... title 0..1 string Title should be the display of the section code
.... code 0..1 CodeableConcept CAP Form Section Identifier
Binding: CAP eCP Section Codes (extensible)
.... entry 1..* Reference(US Pathology Observation) An Observation representing this section in the report and containing (hasMember) Observations representing the question/answers in the section.

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Composition.type Base extensible CAP eCP Form Codes 📦2.0.0 This IG
Composition.event.code Base required v3 Code System ActCode 📍3.0.0 THO v6.5
Composition.section.​code Base extensible CAP eCP Section Codes 📦2.0.0 This IG

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:diagnosticReport-reference 0..1 (Complex) Extension
URL: http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/composition-diagnosticReportReference
..... extension 0..0
..... url 1..1 uri "http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/composition-diagnosticReportReference"
..... value[x] 1..1 Reference(US Pathology Diagnostic Report) Value of extension
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... identifier Σ 0..1 Identifier Report identifier
... status ?!Σ 1..1 code Status of the Report
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type Σ 1..1 CodeableConcept CAP Form Identifier
Binding: CAP eCP Form Codes (extensible)
... subject Σ 1..1 Reference(US Core Patient Profile) Who and/or what the composition is about
... encounter Σ 0..1 Reference(US Core Encounter Profile) The healthcare event which this Report is about (when test ordered).
... date Σ 1..1 dateTime Composition editing time
... author Σ 1..* Reference(US Pathology Related Practitioner Role) Who and/or what authored the Report
... title Σ 1..1 string CAP Form Title
... attester 0..* BackboneElement Attests the report accuracy
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
... section SC 1..* BackboneElement Composition is broken into sections
Constraints: cmp-1, cmp-2
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... title 0..1 string Title should be the display of the section code
.... code 0..1 CodeableConcept CAP Form Section Identifier
Binding: CAP eCP Section Codes (extensible)
.... entry C 1..* Reference(US Pathology Observation) An Observation representing this section in the report and containing (hasMember) Observations representing the question/answers in the section.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base extensible CAP eCP Form Codes 📦2.0.0 This IG
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.section.​code Base extensible CAP eCP Section Codes 📦2.0.0 This IG

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition 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 error Composition 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 error Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... text 0..1 Narrative Narrative text
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:diagnosticReport-reference 0..1 (Complex) Extension
URL: http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/composition-diagnosticReportReference
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/composition-diagnosticReportReference"
..... value[x] 1..1 Reference(US Pathology Diagnostic Report) Value of extension
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
...... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
...... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..1 Identifier Report identifier
... status ?!Σ 1..1 code Status of the Report
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
... type Σ 1..1 CodeableConcept CAP Form Identifier
Binding: CAP eCP Form Codes (extensible)
... category Σ 0..* CodeableConcept Categorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject Σ 1..1 Reference(US Core Patient Profile) Who and/or what the composition is about
... encounter Σ 0..1 Reference(US Core Encounter Profile) The healthcare event which this Report is about (when test ordered).
... date Σ 1..1 dateTime Composition editing time
... author Σ 1..* Reference(US Pathology Related Practitioner Role) Who and/or what authored the Report
... title Σ 1..1 string CAP Form Title
... confidentiality Σ 0..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... attester 0..* BackboneElement Attests the report accuracy
.... 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 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): 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..* BackboneElement Relationships to other compositions/documents
.... 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
.... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... 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
.... code Σ 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: ActCode (3.0.0) (required)
.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... section SC 1..* BackboneElement Composition is broken into sections
Constraints: cmp-1, cmp-2
.... 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 Title should be the display of the section code
.... code 0..1 CodeableConcept CAP Form Section Identifier
Binding: CAP eCP Section Codes (extensible)
.... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
.... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
.... entry C 1..* Reference(US Pathology Observation) An Observation representing this section in the report and containing (hasMember) Observations representing the question/answers in the section.
.... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section C 0..* See section (Composition) Nested Section

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Composition.extension:diagnosticReport-reference.​value[x].type Base extensible ResourceType 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base extensible CAP eCP Form Codes 📦2.0.0 This IG
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.event.code Base required v3 Code System ActCode 📍3.0.0 THO v6.5
Composition.section.​code Base extensible CAP eCP Section Codes 📦2.0.0 This IG
Composition.section.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition 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 error Composition 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 error Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

 

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