This page is part of the FHIR Specification (v3.0.2: STU 3). 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": "2019-10-24T11:53:00+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.