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6.8 Resource Composition - Content

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.

6.8.3 Resource Content

<Composition xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: extension, modifierExtension, language, text, and contained -->
 <identifier><!-- 0..1 Identifier 
     Logical identifier of composition (version-independent) § --></identifier>
 <date value="[dateTime]"/><!-- 1..1 Composition editing time § -->
 <type><!-- 1..1 CodeableConcept Kind of composition (LOINC if possible) § --></type>
 <class><!-- 0..1 CodeableConcept Categorization of Composition § --></class>
 <title value="[string]"/><!-- 0..1 Human Readable name/title § -->
 <status value="[code]"/><!-- 1..1 preliminary | final | appended | amended | entered in error § -->
 <confidentiality><!-- 1..1 Coding As defined by affinity domain § --></confidentiality>
 <subject><!-- 1..1 Resource(Patient|Practitioner|Group|Device|Location) 
     Who and/or what the composition is about § --></subject>
 <author><!-- 1..* Resource(Practitioner|Device|Patient|RelatedPerson) 
     Who and/or what authored the composition § --></author>
 <attester>  <!-- 0..* Attests to accuracy of composition § -->
  <mode value="[code]"/><!-- 1..* personal | professional | legal | official § -->
  <time value="[dateTime]"/><!-- 0..1 When composition attested § -->
  <party><!-- 0..1 Resource(Patient|Practitioner|Organization) Who attested the composition § --></party>
 </attester>
 <custodian><!-- 0..1 Resource(Organization) Org which maintains the composition § --></custodian>
 <event>  <!-- 0..1 The clinical event/act/item being documented § -->
  <code><!-- 0..* CodeableConcept Code(s) that apply to the event being documented § --></code>
  <period><!-- 0..1 Period The period covered by the documentation § --></period>
  <detail><!-- 0..* Resource(Any) Full details for the event(s) the composition consents § --></detail>
 </event>
 <encounter><!-- 0..1 Resource(Encounter) Context of the conposition § --></encounter>
 <section>  <!-- 0..* Composition is broken into sections -->
  <title value="[string]"/><!-- 0..1 Label for section -->
  <code><!-- 0..1 CodeableConcept Classification of section (recommended) --></code>
  <subject><!-- 0..1 Resource(Patient|Group|Device) If section different to composition --></subject>
  <content><!--  0..1 Resource(Any) The actual data for the section --></content>
  <section><!--  0..* Content as for Composition.section Nested Section --></section>
 </section>
</Composition>

Alternate definitions: Schema/Schematron, Resource Profile

6.8.3.1 Terminology Bindings

6.8.3.2 Constraints

• Inv-2: On Composition.section: A section SHALL have content or one or more sections, but not both. (xpath on f:Composition/f:section: exists(f:content) != exists(f:section))

6.8.4 Notes:

• The author and the attester are often the same person, but this may not be the case in some clinical workflows
• The attester attests contents of the document resource, the subject resource and the resources referred to in the Composition.section.content references. Because documents are often derived Compositions and the attestation from the composition is held to apply to the document, the method for presenting a document should be used when/if attesters review the content of the composition
• The custodian is responsible for the maintenance of the composition and any documents derived from it. With regard to the documents, they are responsible for the policy regarding persistence of the documents. Although they need not actually retain a copy of the document, they SHOULD do so.
• Narrative only sections can be created by setting Content to a resource of the appropriate type and only populating the narrative portion of the resource. If the meaning of the section is such that an appropriate resource does not exist, the Other resource should be used. (In some cases, the a resource may have mandatory elements that preclude the resource containing only narrative. This will be addressed in a future release, but for now, Other should be used in these circumstances as well.)

6.8.5 Search Parameters

Search parameters for this resource. The standard parameters also apply. See Searching for more information about searching in REST, messaging, and services.