Release 5

This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

Structured Documents icon Work Group Maturity Level: 0Trial Use Use Context: Any

The canonical URL for this profile is:

http://hl7.org/fhir/StructureDefinition/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.

This profile was published on Thu, Jan 1, 1970 00:00+1000 as a draft by HL7.

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

This structure is derived from Composition.

Summary

This indicates the differences between this profile and the base Composition structure.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... subject 0..*Reference(Patient | Practitioner | Group | Device | Location)Who and/or what the composition is about

doco Documentation for this format icon

This provides the consolidated view (aka snapshot) of the profile after applying the changes in this profile to the base Composition structure.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: All Languages (required): IETF language tag for a human language

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
... url Σ0..1uriCanonical identifier for this Composition, represented as a URI (globally unique)
... identifier Σ0..*IdentifierVersion-independent identifier for the Composition
... version Σ0..1stringAn explicitly assigned identifer of a variation of the content in the Composition
... status ?!Σ1..1coderegistered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
Binding: Composition Status (required): The workflow/clinical status of the composition.

... type Σ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIR Document Type Codes (preferred): Type of a composition.

... category Σ0..*CodeableConceptCategorization of Composition
Binding: Referenced Item Category Value Set (example): High-level kind of a clinical document at a macro level.


... subject Σ0..*Reference(Patient | Practitioner | Group | Device | Location)Who and/or what the composition is about
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date Σ1..1dateTimeComposition editing time
... useContext Σ0..*UsageContextThe context that the content is intended to support
... author Σ1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the composition
... name Σ0..1stringName for this Composition (computer friendly)
... title Σ1..1stringHuman Readable name/title
... note 0..*AnnotationFor any additional notes
... attester 0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1CodeableConceptpersonal | professional | legal | official
Binding: Composition Attestation Mode (preferred): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo 0..*RelatedArtifactRelationships to other compositions/documents
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*CodeableReference(Resource)The event(s) being documented, as code(s), reference(s), or both
Binding: v3 Code System ActCode icon (example): This list of codes represents the main clinical acts being documented.


... section C icon0..*BackboneElementComposition is broken into sections
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: Document Section Codes (example): Classification of a section of a composition/document.

.... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text C icon0..1NarrativeText summary of the section, for human interpretation
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred): What order applies to the items in the entry.

.... entry C icon0..*Reference(Resource)A reference to data that supports this section
.... emptyReason C icon0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred): If a section is empty, why it is empty.

.... section 0..*See section (Composition)Nested Section

doco Documentation for this format icon
<!-- ClinicalDocument -->doco

<Composition xmlns="http://hl7.org/fhir"
>
  <!-- from Element: extension -->
 <id value="[id]"/><!-- 0..1 Logical id of this artifact -->
 <meta><!-- I 0..1 Meta Metadata about the resource --></meta>
 <implicitRules value="[uri]"/><!-- I 0..1 A set of rules under which this content was created -->
 <language value="[code]"/><!-- I 0..1 Language of the resource content   -->
 <text><!-- I 0..1 Narrative 
     Text summary of the resource, for human interpretation --></text>
 <contained><!-- 0..* Resource Contained, inline Resources --></contained>
 <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
 <url value="[uri]"/><!-- I 0..1 Canonical identifier for this Composition, represented as a URI (globally unique) -->
 <identifier><!-- I 0..* Identifier 
     Version-independent identifier for the Composition --></identifier>
 <version value="[string]"/><!-- I 0..1 
     An explicitly assigned identifer of a variation of the content in the Composition -->
 <status value="[code]"/><!-- I 1..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown   -->
 <type><!-- I 1..1 CodeableConcept Kind of composition (LOINC if possible)   --></type>
 <category><!-- I 0..* CodeableConcept Categorization of Composition   --></category>
 <subject><!-- I 0..* Reference(Patient) 
     Who and/or what the composition is about --></subject>
 <encounter><!-- I 0..1 Reference(Encounter) Context of the Composition --></encounter>
 <date value="[dateTime]"/><!-- I 1..1 Composition editing time -->
 <useContext><!-- I 0..* UsageContext 
     The context that the content is intended to support --></useContext>
 <author><!-- I 1..* Reference(Practitioner) 
     Who and/or what authored the composition --></author>
 <name value="[string]"/><!-- I 0..1 Name for this Composition (computer friendly) -->
 <title value="[string]"/><!-- I 1..1 Human Readable name/title -->
 <note><!-- I 0..* Annotation For any additional notes --></note>
 <attester> I 0..* BackboneElement  <!-- I 0..* Attests to accuracy of composition -->
  <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <mode><!-- I 1..1 CodeableConcept personal | professional | legal | official   --></mode>
  <time value="[dateTime]"/><!-- I 0..1 When the composition was attested -->
  <party><!-- I 0..1 Reference(Patient) 
      Who attested the composition --></party>
 </attester>
 <custodian><!-- I 0..1 Reference(Organization) 
     Organization which maintains the composition --></custodian>
 <relatesTo><!-- I 0..* RelatedArtifact 
     Relationships to other compositions/documents --></relatesTo>
 <event> I 0..* BackboneElement  <!-- I 0..* The clinical service(s) being documented -->
  <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <period><!-- I 0..1 Period 
      The period covered by the documentation --></period>
  <detail><!-- I 0..* CodeableReference The event(s) being documented, as code(s), reference(s), or both icon   --></detail>
 </event>
 <section> I 0..* BackboneElement  <!-- I 0..* Composition is broken into sections -->
  <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <title value="[string]"/><!-- I 0..1 Label for section (e.g. for ToC) -->
  <code><!-- I 0..1 CodeableConcept Classification of section (recommended)   --></code>
  <author><!-- I 0..* Reference(Practitioner) 
      Who and/or what authored the section --></author>
  <focus><!-- I 0..1 Reference(Resource) 
      Who/what the section is about, when it is not about the subject of composition --></focus>
  <text><!-- I 0..1 Narrative 
      Text summary of the section, for human interpretation --></text>
  <orderedBy><!-- I 0..1 CodeableConcept Order of section entries   --></orderedBy>
  <entry><!-- I 0..* Reference(Resource) 
      A reference to data that supports this section --></entry>
  <emptyReason><!-- I 0..1 CodeableConcept Why the section is empty   --></emptyReason>
  <section><!-- See http://hl7.org/fhir/StructureDefinition/Composition#Composition.section  Nested Section --></section>
 </section>
</Composition>
{ // ClinicalDocument
  // from Element: extension
    "meta" : { Meta }, // IMetadata about the resource
    "implicitRules" : "<uri>", // IA set of rules under which this content was created
    "language" : "<code>", // ILanguage of the resource content
    "text" : { Narrative }, // IText summary of the resource, for human interpretation
    "contained" : [{ Resource }], //Contained, inline Resources
    "modifierExtension" : [{ Extension }], // IExtensions that cannot be ignored
    "url" : "<uri>", // ICanonical identifier for this Composition, represented as a URI (globally unique)
    "identifier" : [{ Identifier }], // IVersion-independent identifier for the Composition
    "version" : "<string>", // IAn explicitly assigned identifer of a variation of the content in the Composition
    "status" : "<code>", // I R! registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
    "type" : { CodeableConcept }, // I R! Kind of composition (LOINC if possible)
    "category" : [{ CodeableConcept }], // ICategorization of Composition
    "subject" : [{ Reference(Patient) }], // IWho and/or what the composition is about
    "encounter" : { Reference(Encounter) }, // IContext of the Composition
    "date" : "<dateTime>", // I R! Composition editing time
    "useContext" : [{ UsageContext }], // IThe context that the content is intended to support
    "author" : [{ Reference(Practitioner) }], // I R! Who and/or what authored the composition
    "name" : "<string>", // IName for this Composition (computer friendly)
    "title" : "<string>", // I R! Human Readable name/title
    "note" : [{ Annotation }], // IFor any additional notes
    "attester" : [{ BackboneElement }], // IAttests to accuracy of composition
    "custodian" : { Reference(Organization) }, // IOrganization which maintains the composition
    "relatesTo" : [{ RelatedArtifact }], // IRelationships to other compositions/documents
    "event" : [{ BackboneElement }], // IThe clinical service(s) being documented
    "section" : [{ BackboneElement }] // IComposition is broken into sections
  }

This structure is derived from Composition.

Summary

Differential View

This indicates the differences between this profile and the base Composition structure.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... subject 0..*Reference(Patient | Practitioner | Group | Device | Location)Who and/or what the composition is about

doco Documentation for this format icon

Snapshot View

This provides the consolidated view (aka snapshot) of the profile after applying the changes in this profile to the base Composition structure.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: All Languages (required): IETF language tag for a human language

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
... url Σ0..1uriCanonical identifier for this Composition, represented as a URI (globally unique)
... identifier Σ0..*IdentifierVersion-independent identifier for the Composition
... version Σ0..1stringAn explicitly assigned identifer of a variation of the content in the Composition
... status ?!Σ1..1coderegistered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
Binding: Composition Status (required): The workflow/clinical status of the composition.

... type Σ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIR Document Type Codes (preferred): Type of a composition.

... category Σ0..*CodeableConceptCategorization of Composition
Binding: Referenced Item Category Value Set (example): High-level kind of a clinical document at a macro level.


... subject Σ0..*Reference(Patient | Practitioner | Group | Device | Location)Who and/or what the composition is about
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date Σ1..1dateTimeComposition editing time
... useContext Σ0..*UsageContextThe context that the content is intended to support
... author Σ1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the composition
... name Σ0..1stringName for this Composition (computer friendly)
... title Σ1..1stringHuman Readable name/title
... note 0..*AnnotationFor any additional notes
... attester 0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1CodeableConceptpersonal | professional | legal | official
Binding: Composition Attestation Mode (preferred): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo 0..*RelatedArtifactRelationships to other compositions/documents
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*CodeableReference(Resource)The event(s) being documented, as code(s), reference(s), or both
Binding: v3 Code System ActCode icon (example): This list of codes represents the main clinical acts being documented.


... section C icon0..*BackboneElementComposition is broken into sections
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: Document Section Codes (example): Classification of a section of a composition/document.

.... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text C icon0..1NarrativeText summary of the section, for human interpretation
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred): What order applies to the items in the entry.

.... entry C icon0..*Reference(Resource)A reference to data that supports this section
.... emptyReason C icon0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred): If a section is empty, why it is empty.

.... section 0..*See section (Composition)Nested Section

doco Documentation for this format icon

XML Template

<!-- ClinicalDocument -->doco

<Composition xmlns="http://hl7.org/fhir"
>
  <!-- from Element: extension -->
 <id value="[id]"/><!-- 0..1 Logical id of this artifact -->
 <meta><!-- I 0..1 Meta Metadata about the resource --></meta>
 <implicitRules value="[uri]"/><!-- I 0..1 A set of rules under which this content was created -->
 <language value="[code]"/><!-- I 0..1 Language of the resource content   -->
 <text><!-- I 0..1 Narrative 
     Text summary of the resource, for human interpretation --></text>
 <contained><!-- 0..* Resource Contained, inline Resources --></contained>
 <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
 <url value="[uri]"/><!-- I 0..1 Canonical identifier for this Composition, represented as a URI (globally unique) -->
 <identifier><!-- I 0..* Identifier 
     Version-independent identifier for the Composition --></identifier>
 <version value="[string]"/><!-- I 0..1 
     An explicitly assigned identifer of a variation of the content in the Composition -->
 <status value="[code]"/><!-- I 1..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown   -->
 <type><!-- I 1..1 CodeableConcept Kind of composition (LOINC if possible)   --></type>
 <category><!-- I 0..* CodeableConcept Categorization of Composition   --></category>
 <subject><!-- I 0..* Reference(Patient) 
     Who and/or what the composition is about --></subject>
 <encounter><!-- I 0..1 Reference(Encounter) Context of the Composition --></encounter>
 <date value="[dateTime]"/><!-- I 1..1 Composition editing time -->
 <useContext><!-- I 0..* UsageContext 
     The context that the content is intended to support --></useContext>
 <author><!-- I 1..* Reference(Practitioner) 
     Who and/or what authored the composition --></author>
 <name value="[string]"/><!-- I 0..1 Name for this Composition (computer friendly) -->
 <title value="[string]"/><!-- I 1..1 Human Readable name/title -->
 <note><!-- I 0..* Annotation For any additional notes --></note>
 <attester> I 0..* BackboneElement  <!-- I 0..* Attests to accuracy of composition -->
  <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <mode><!-- I 1..1 CodeableConcept personal | professional | legal | official   --></mode>
  <time value="[dateTime]"/><!-- I 0..1 When the composition was attested -->
  <party><!-- I 0..1 Reference(Patient) 
      Who attested the composition --></party>
 </attester>
 <custodian><!-- I 0..1 Reference(Organization) 
     Organization which maintains the composition --></custodian>
 <relatesTo><!-- I 0..* RelatedArtifact 
     Relationships to other compositions/documents --></relatesTo>
 <event> I 0..* BackboneElement  <!-- I 0..* The clinical service(s) being documented -->
  <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <period><!-- I 0..1 Period 
      The period covered by the documentation --></period>
  <detail><!-- I 0..* CodeableReference The event(s) being documented, as code(s), reference(s), or both icon   --></detail>
 </event>
 <section> I 0..* BackboneElement  <!-- I 0..* Composition is broken into sections -->
  <modifierExtension><!-- I 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <title value="[string]"/><!-- I 0..1 Label for section (e.g. for ToC) -->
  <code><!-- I 0..1 CodeableConcept Classification of section (recommended)   --></code>
  <author><!-- I 0..* Reference(Practitioner) 
      Who and/or what authored the section --></author>
  <focus><!-- I 0..1 Reference(Resource) 
      Who/what the section is about, when it is not about the subject of composition --></focus>
  <text><!-- I 0..1 Narrative 
      Text summary of the section, for human interpretation --></text>
  <orderedBy><!-- I 0..1 CodeableConcept Order of section entries   --></orderedBy>
  <entry><!-- I 0..* Reference(Resource) 
      A reference to data that supports this section --></entry>
  <emptyReason><!-- I 0..1 CodeableConcept Why the section is empty   --></emptyReason>
  <section><!-- See http://hl7.org/fhir/StructureDefinition/Composition#Composition.section  Nested Section --></section>
 </section>
</Composition>

JSON Template

{ // ClinicalDocument
  // from Element: extension
    "meta" : { Meta }, // IMetadata about the resource
    "implicitRules" : "<uri>", // IA set of rules under which this content was created
    "language" : "<code>", // ILanguage of the resource content
    "text" : { Narrative }, // IText summary of the resource, for human interpretation
    "contained" : [{ Resource }], //Contained, inline Resources
    "modifierExtension" : [{ Extension }], // IExtensions that cannot be ignored
    "url" : "<uri>", // ICanonical identifier for this Composition, represented as a URI (globally unique)
    "identifier" : [{ Identifier }], // IVersion-independent identifier for the Composition
    "version" : "<string>", // IAn explicitly assigned identifer of a variation of the content in the Composition
    "status" : "<code>", // I R! registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
    "type" : { CodeableConcept }, // I R! Kind of composition (LOINC if possible)
    "category" : [{ CodeableConcept }], // ICategorization of Composition
    "subject" : [{ Reference(Patient) }], // IWho and/or what the composition is about
    "encounter" : { Reference(Encounter) }, // IContext of the Composition
    "date" : "<dateTime>", // I R! Composition editing time
    "useContext" : [{ UsageContext }], // IThe context that the content is intended to support
    "author" : [{ Reference(Practitioner) }], // I R! Who and/or what authored the composition
    "name" : "<string>", // IName for this Composition (computer friendly)
    "title" : "<string>", // I R! Human Readable name/title
    "note" : [{ Annotation }], // IFor any additional notes
    "attester" : [{ BackboneElement }], // IAttests to accuracy of composition
    "custodian" : { Reference(Organization) }, // IOrganization which maintains the composition
    "relatesTo" : [{ RelatedArtifact }], // IRelationships to other compositions/documents
    "event" : [{ BackboneElement }], // IThe clinical service(s) being documented
    "section" : [{ BackboneElement }] // IComposition is broken into sections
  }

 

Alternate definitions: Master Definition (XML, JSON), Schematron

PathNameConformanceValueSet
Composition.languageAll LanguagesrequiredAll Languages
Composition.statusComposition StatusrequiredComposition Status
Composition.typeFHIR Document Type CodespreferredFHIR Document Type Codes
Composition.categoryReferenced Item Category Value SetexampleReferenced Item Category Value Set
Composition.attester.modeComposition Attestation ModepreferredComposition Attestation Mode
Composition.event.detailv3 Code System ActCodeexamplev3 Code System ActCode icon
Composition.section.codeDocument Section CodesexampleDocument Section Codes
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
. .