Composition - FHIR v0.0.82

This page is part of the FHIR Specification (v0.0.82: DSTU 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: R5 R4B R4 R3 R2

6.8.7 Resource Composition - Formal Definitions

Formal definitions for the elements in the Composition resource.

Composition
Definition	A set of healthcare-related information that is assembled together into a single logical document 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.
Control	1..1
Requirements	To support documents, and also to capture the EN13606 notion of an attested commit to the patient EHR, and to allow a set of disparate resources at the information/engineering level to be gathered into a clinical statement.
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.
Composition.identifier
Definition	Logical Identifier for the composition, assigned when created. This identifier stays constant as the composition is changed over time.
Control	0..1
Type	Identifier
Summary	true
Comments	See discussion in resource definition for how these relate.
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.
Summary	true
Comments	The Last Modified Date on the composition may be after the date of the document was attested without being changed.
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	DocumentType: (See http://hl7.org/fhir/vs/doc-codes)
Type	CodeableConcept
Requirements	Key metadata element describing the composition, used in searching/filtering.
Summary	true
Composition.class
Definition	A categorization for the type of the composition. This may be implied by or derived from the code specified in the Composition Type.
Control	0..1
Binding	DocumentClass: (See http://hl7.org/fhir/vs/xds-typecodes)
Type	CodeableConcept
Requirements	Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.
Summary	true
Composition.title
Definition	Official human-readable label for the composition.
Control	0..1
Type	string
Summary	true
Comments	If compositions do not have a title, the text or a display name of Composition.type (e.g. a "consultation" or "progress note") can be used in it's place.
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	CompositionStatus: The workflow/clinical status of the composition (see http://hl7.org/fhir/composition-status for values)
Type	code
Is Modifier	true
Requirements	Need to be able to mark interim, amended, or withdrawn compositions or documents.
Summary	true
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 "withdrawn" is why this element is labeled as a modifier of other elements.
Composition.confidentiality
Definition	The code specifying the level of confidentiality of the Composition.
Control	1..1
Binding	DocumentConfidentiality: Codes specifying the level of confidentiality of the composition (Value Set Definition)
Type	Coding
Is Modifier	true
Summary	true
Comments	The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for FHIR, and delegated to implementation profiles (see security section).
Composition.subject
Definition	Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (I.e. 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	Resource(Patient \| Practitioner \| Group \| Device \| Location)
Requirements	Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.
Summary	true
Comments	For clinical documents, this is usually the patient.
Composition.author
Definition	Identifies who is responsible for the information in the composition. (Not necessarily who typed it in.).
Control	1..*
Type	Resource(Practitioner \| Device \| Patient \| RelatedPerson)
Requirements	Identifies who is responsible for the content.
Summary	true
Composition.attester
Definition	A participant who has attested to the accuracy of the composition/document.
Control	0..*
Requirements	Identifies responsibility for the accuracy of the composition content.
Summary	true
Comments	Only list each attester once.
Composition.attester.mode
Definition	The type of attestation the authenticator offers.
Control	1..*
Binding	CompositionAttestationMode: The way in which a person authenticated a composition (see http://hl7.org/fhir/composition-attestation-mode for values)
Type	code
Requirements	Indicates the level of officialness of the attestation.
Summary	true
Comments	Use more than one code where a single attester has more than one mode (professional and legal are often paired).
Composition.attester.time
Definition	When 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.).
Summary	true
Composition.attester.party
Definition	Who attested the composition in the specified way.
Control	0..1
Type	Resource(Patient \| Practitioner \| Organization)
Requirements	Identifies who has taken on the responsibility for accuracy of the composition content.
Summary	true
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	Resource(Organization)
Requirements	Identifies where to go to find the current version, where to report issues, etc.
Summary	true
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 knowing this is sometimes not known by the authoring system, and can be inferred by context. However it's important that this information be known when working with a derived document, so providing a custodian is encouraged.
Composition.event
Definition	The main event/act/item, such as a colonoscopy or an appendectomy, being documented.
Control	0..1
Requirements	Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.
Summary	true
Comments	The event needs to be consistent with the type element, though can provide further information if desired.
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	DocumentEventType: This list of codes represents the main clinical acts being documented (Value Set Definition)
Type	CodeableConcept
Summary	true
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.
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
Summary	true
Composition.event.detail
Definition	Full details for the event(s) the composition/documentation consents.
Control	0..*
Type	Resource(Any)
Summary	true
Composition.encounter
Definition	Describes the clinical encounter or type of care this documentation is associated with.
Control	0..1
Type	Resource(Encounter)
Requirements	Provides context for the composition and supports searching.
Summary	true
Composition.section
Definition	The root of the sections that make up the composition.
Control	0..*
Invariants	Defined on this element Inv-2: A section SHALL have content or one or more sections, but not both. (xpath: exists(f:content) != exists(f:section))
Composition.section.title
Definition	The heading for this particular section. This will be part of the rendered content for the document.
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.
Composition.section.code
Definition	A code identifying the kind of content contained within the section.
Control	0..1
Binding	CompositionSectionType: (See http://hl7.org/fhir/vs/doc-section-codes)
Type	CodeableConcept
Requirements	Provides computable standardized labels to topics within the document.
Composition.section.subject
Definition	Identifies the primary subject of the section.
Control	0..1
Type	Resource(Patient \| Group \| Device)
Is Modifier	true
Requirements	Subjects can vary within one composition or document, for example mother/baby, patient & relatives, etc.
Comments	This is labeled as "Is Modifier" because applications SHALL be aware if the subject changes for a particular section.
Composition.section.content
Definition	Identifies the discrete data that provides the content for the section.
Control	0..1
Type	Resource(Any)
Requirements	Conveys the discrete data associated with the composition.
Comments	Because composition represent point-in-time snapshots, resource references should either be to a specific version, or made against resources on the same server with full version tracking, so that the correct versions can easily be assembled.
Invariants	Affect this element Inv-2: A section SHALL have content or one or more sections, but not both. (xpath: exists(f:content) != exists(f:section))
Composition.section.section
Definition	A nested sub-section within this section.
Control	0..*
Type	See Composition.section
Invariants	Affect this element Inv-2: A section SHALL have content or one or more sections, but not both. (xpath: exists(f:content) != exists(f:section))