This page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R4 R3
Vocabulary Work Group | Maturity Level: N/A | Ballot Status: Informative |
A clinical document is a documentation of clinical observations and services, with the following characteristics: (1) Persistence - A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements; (2) Stewardship - A clinical document is maintained by a person or organization entrusted with its care; (3) Potential for authentication - A clinical document is an assemblage of information that is intended to be legally authenticated; (4) Wholeness - Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document; (5) Human readability - A clinical document is human readable."
{ "resourceType": "ValueSet", "id": "v3-ActClassClinicalDocument", "meta": { "lastUpdated": "2017-12-20T15:52:34.818+11:00", "profile": [ "http://hl7.org/fhir/StructureDefinition/shareablevalueset" ] }, "text": { "status": "generated", "div": "<div>!-- Snipped for Brevity --></div>" }, "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-ballot-status", "valueString": "External" }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm", "valueInteger": 0 } ], "url": "http://hl7.org/fhir/ValueSet/v3-ActClassClinicalDocument", "identifier": [ { "system": "urn:ietf:rfc:3986", "value": "urn:oid:2.16.840.1.113883.1.11.13948" } ], "version": "2014-03-26", "name": "ActClassClinicalDocument", "status": "active", "experimental": false, "publisher": "HL7 v3", "contact": [ { "telecom": [ { "system": "url", "value": "http://www.hl7.org" } ] } ], "description": " A clinical document is a documentation of clinical observations and services, with the following characteristics: (1) Persistence - A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements; (2) Stewardship - A clinical document is maintained by a person or organization entrusted with its care; (3) Potential for authentication - A clinical document is an assemblage of information that is intended to be legally authenticated; (4) Wholeness - Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document; (5) Human readability - A clinical document is human readable.\"", "immutable": true, "compose": { "include": [ { "system": "http://hl7.org/fhir/v3/ActClass", "filter": [ { "property": "concept", "op": "is-a", "value": "DOCCLIN" } ] } ] } }
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.