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This page is part of the C-CDA on FHIR Implementation Guide (v1.8.0: STU 1 Ballot 2) based on FHIR v1.8.0. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions 
The official URL for this profile is:
http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-US-Realm-Header
This profile defines constraints that represent common administrative and demographic concepts for US Realm clinical documents. Further specification, such as type, are provided in document profiles that conform to this profile.
This profile builds on Composition.
This profile was published on Thu Dec 08 06:39:19 AEDT 2016 as a draft by null.
Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.
This structure is derived from Composition
Summary
Mandatory: 10 elements (+2 nested mandatory elements)
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
This structure is derived from Composition
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  id | ∑ | 0..1 | id | Logical id of this artifact |
 meta | ∑ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!∑ | 0..1 | uri | A set of rules under which this content was created |
| language | 1..1 | code | language Binding: Common Languages (extensible) | |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
 contained | 0..* | Resource | Contained, inline Resources | |
 extension | Extension | Extension Slice: Unordered, Open, by Composition.url | ||
 CCDA-on-FHIR-Data-Enterer | 0..1 | Reference(US Core Practitioner) | dataEnterer URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer | |
| CCDA-on-FHIR-Informant | 0..* | Reference(US Core Practitioner) | informant URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Informant | |
| CCDA-on-FHIR-Information-Recipient | 0..* | Reference(US Core Practitioner) | informationRecipient URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient | |
| CCDA-on-FHIR-Participant | 0..* | Reference(RelatedPerson) | participant URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Participant | |
| CCDA-on-FHIR-Performer | 0..* | Reference(US Core Practitioner) | performer URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Performer | |
| CCDA-on-FHIR-Authorization | 0..* | Reference(C-CDA on FHIR Consent) | authorization URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ∑ | 1..1 | Identifier | identifier |
| date | ∑ | 1..1 | dateTime | date |
| type | ∑ | 1..1 | CodeableConcept | Document Type Binding: FHIR Document Type Codes (preferred) |
| class | ∑ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
| title | ∑ | 1..1 | string | Document Title |
| status | ?!∑ | 1..1 | code | status Binding: CompositionStatus (required) |
| confidentiality | ?!∑ | 1..1 | code | confidentiality Binding: ConfidentialityClassification (required) |
 subject | ∑ | 1..1 | Reference(US Core Patient Profile) | recordTarget |
| author | ∑ | 1..* | Reference(US Core Practitioner), Reference(Device) | author |
| attester | ∑I | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open, by Composition.attester.mode | |
| attester | ∑I | 0..1 | BackboneElement | attester |
 id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| mode | ∑ | 1..1 | code | mode Binding: CompositionAttestationMode (required) Required Pattern: legal |
| time | ∑ | 0..1 | dateTime | When composition attested |
 party | ∑ | 0..1 | Reference(US Core Practitioner) | party |
| attester | ∑I | 0..* | BackboneElement | attester |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| mode | ∑ | 1..* | code | mode Binding: CompositionAttestationMode (required) |
| time | ∑ | 0..1 | dateTime | When composition attested |
| party | ∑ | 0..1 | Reference(US Core Practitioner) | party |
| custodian | ∑ | 1..1 | Reference(US Core Organization Profile) | custodian |
| event | ∑I | 0..* | BackboneElement | The clinical service(s) being documented |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| code | ∑ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
| period | ∑ | 0..1 | Period | The period covered by the documentation |
| detail | ∑ | 0..* | Reference(Resource) | The event(s) being documented |
| encounter | ∑ | 0..1 | Reference(Encounter) | Context of the Composition |
| section | I | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
 id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Document Section Codes (example) | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirusrealmheader.section Nested Section | |
| Documentation for this format | ||||
This structure is derived from Composition
Summary
Mandatory: 10 elements (+2 nested mandatory elements)
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Composition
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | I | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| id | ∑ | 0..1 | id | Logical id of this artifact |
| meta | ∑ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!∑ | 0..1 | uri | A set of rules under which this content was created |
| language | 1..1 | code | language Binding: Common Languages (extensible) | |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | Extension | Extension Slice: Unordered, Open, by Composition.url | ||
| CCDA-on-FHIR-Data-Enterer | 0..1 | Reference(US Core Practitioner) | dataEnterer URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer | |
| CCDA-on-FHIR-Informant | 0..* | Reference(US Core Practitioner) | informant URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Informant | |
| CCDA-on-FHIR-Information-Recipient | 0..* | Reference(US Core Practitioner) | informationRecipient URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient | |
| CCDA-on-FHIR-Participant | 0..* | Reference(RelatedPerson) | participant URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Participant | |
| CCDA-on-FHIR-Performer | 0..* | Reference(US Core Practitioner) | performer URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Performer | |
| CCDA-on-FHIR-Authorization | 0..* | Reference(C-CDA on FHIR Consent) | authorization URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ∑ | 1..1 | Identifier | identifier |
| date | ∑ | 1..1 | dateTime | date |
| type | ∑ | 1..1 | CodeableConcept | Document Type Binding: FHIR Document Type Codes (preferred) |
| class | ∑ | 0..1 | CodeableConcept | Categorization of Composition Binding: FHIR Document Class Codes (example) |
| title | ∑ | 1..1 | string | Document Title |
| status | ?!∑ | 1..1 | code | status Binding: CompositionStatus (required) |
| confidentiality | ?!∑ | 1..1 | code | confidentiality Binding: ConfidentialityClassification (required) |
| subject | ∑ | 1..1 | Reference(US Core Patient Profile) | recordTarget |
| author | ∑ | 1..* | Reference(US Core Practitioner), Reference(Device) | author |
| attester | ∑I | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open, by Composition.attester.mode | |
| attester | ∑I | 0..1 | BackboneElement | attester |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| mode | ∑ | 1..1 | code | mode Binding: CompositionAttestationMode (required) Required Pattern: legal |
| time | ∑ | 0..1 | dateTime | When composition attested |
| party | ∑ | 0..1 | Reference(US Core Practitioner) | party |
| attester | ∑I | 0..* | BackboneElement | attester |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| mode | ∑ | 1..* | code | mode Binding: CompositionAttestationMode (required) |
| time | ∑ | 0..1 | dateTime | When composition attested |
| party | ∑ | 0..1 | Reference(US Core Practitioner) | party |
| custodian | ∑ | 1..1 | Reference(US Core Organization Profile) | custodian |
| event | ∑I | 0..* | BackboneElement | The clinical service(s) being documented |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| code | ∑ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example) |
| period | ∑ | 0..1 | Period | The period covered by the documentation |
| detail | ∑ | 0..* | Reference(Resource) | The event(s) being documented |
| encounter | ∑ | 0..1 | Reference(Encounter) | Context of the Composition |
| section | I | 0..* | BackboneElement | Composition is broken into sections cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!∑ | 0..* | Extension | Extensions that cannot be ignored |
| title | 0..1 | string | Label for section (e.g. for ToC) | |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: Document Section Codes (example) | |
| text | I | 0..1 | Narrative | Text summary of the section, for human interpretation |
| mode | ?!∑ | 0..1 | code | working | snapshot | changes Binding: ListMode (required) |
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: List Order Codes (preferred) | |
| entry | I | 0..* | Reference(Resource) | A reference to data that supports this section |
| emptyReason | I | 0..1 | CodeableConcept | Why the section is empty Binding: List Empty Reasons (preferred) |
| section | I | 0..* | Unknown reference to #Composition:c-cdaonfhirusrealmheader.section Nested Section | |
| Documentation for this format | ||||
Downloads: StructureDefinition: (XML, JSON, CSV), Schema: XML Schematron
| Path | Name | Conformance | ValueSet |
| Composition.language | Common Languages | extensible | Common Languages |
| Composition.type | FHIR Document Type Codes | preferred | FHIR Document Type Codes |
| Composition.class | FHIR Document Class Codes | example | FHIR Document Class Codes |
| Composition.status | CompositionStatus | required | CompositionStatus |
| Composition.confidentiality | ConfidentialityClassification | required | ConfidentialityClassification |
| Composition.attester.mode | CompositionAttestationMode | required | CompositionAttestationMode |
| Composition.attester.mode | CompositionAttestationMode | required | CompositionAttestationMode |
| Composition.event.code | v3 Code System ActCode | example | v3 Code System ActCode |
| Composition.section.code | Document Section Codes | example | Document Section Codes |
| Composition.section.mode | ListMode | required | ListMode |
| Composition.section.orderedBy | List Order Codes | preferred | List Order Codes |
| Composition.section.emptyReason | List Empty Reasons | preferred | List Empty Reasons |
| Id | Path | Details | Requirements |
| dom-2 | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources XPath: not(parent::f:contained and f:contained) | |
| dom-1 | Composition | If the resource is contained in another resource, it SHALL NOT contain any narrative XPath: not(parent::f:contained and f:text) | |
| dom-4 | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated XPath: not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated)) | |
| dom-3 | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource XPath: not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))])) | |
| ele-1 | Composition.attester | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
| ele-1 | Composition.attester | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
| ele-1 | Composition.attester | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
| ele-1 | Composition.event | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
| ele-1 | Composition.section | All FHIR elements must have a @value or children XPath: @value|f:*|h:div | |
| cmp-1 | Composition.section | A section must at least one of text, entries, or sub-sections XPath: exists(f:text) or exists(f:entry) or exists(f:section) | |
| cmp-2 | Composition.section | A section can only have an emptyReason if it is empty XPath: not(exists(f:emptyReason) and exists(f:entry)) |
© HL7.org 2011+. FHIR STU3 Candidate (v1.8.0-10514) generated on Thu, Dec 8, 2016 06:39+1100. QA Page
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