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2.42.15 Clinical Document

Structured Documents Work Group

Maturity Level: N/A

Standards Status: Informative

The Clinical Document profile constrains Composition to specify a clinical document (matching CDA). The base Composition is a general resource for compositions or documents about any kind of subject that might be encountered in healthcare including such things as guidelines, medicines, etc. A clinical document is focused on documents related to the provision of care process, where the subject is a patient, a group of patients, or a closely related concept. A clinical document has additional requirements around confidentiality that do not apply in the same way to other kinds of documents.

2.42.15.1 Content

Profiles:
ClinicalDocument	The Clinical Document profile constrains Composition to specify a clinical document (matching CDA). The base Composition is a general resource for compositions or documents about any kind of subject that might be encountered in healthcare including such things as guidelines, medicines, etc. A clinical document is focused on documents related to the provision of care process, where the subject is a patient, a group of patients, or a closely related concept. A clinical document has additional requirements around confidentiality that do not apply in the same way to other kinds of documents.
Extensions:
composition-clinicaldocument-otherConfidentiality	otherConfidentiality : Carries additional confidentiality codes beyond the base fixed code specified in the CDA document.
composition-clinicaldocument-versionNumber	versionNumber : Version specific identifier for the composition, assigned when each version is created/updated.