Path | Short | Definition | Comments |
---|---|---|---|
A set of resources composed into a single coherent clinical statement with clinical attestation | A set of healthcare-related information that is assembled together into a single logical package 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. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). | 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. | |
identifier | Version-independent identifier for the Composition | A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time. | Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate. |
status | preliminary | final | amended | entered-in-error | The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. | If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as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 "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. |
type | Kind of composition (LOINC if possible) | 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. | For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. |
category | Categorization of Composition | A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type. | This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)). |
subject | Who and/or what the composition is about | Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a 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). | For clinical documents, this is usually the patient. |
encounter | Context of the Composition | Describes the clinical encounter or type of care this documentation is associated with. | |
date | Composition editing time | The composition editing time, when the composition was last logically changed by the author. | The Last Modified Date on the composition may be after the date of the document was attested without being changed. |
author | Who and/or what authored the composition | Identifies who is responsible for the information in the composition, not necessarily who typed it in. | |
title | Human Readable name/title | Official human-readable label for the composition. | For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period. |
confidentiality | As defined by affinity domain | The code specifying the level of confidentiality of the Composition. | The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. |
attester | Attests to accuracy of composition | A participant who has attested to the accuracy of the composition/document. | Only list each attester once. |
attester.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
attester.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
attester.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
attester.mode | personal | professional | legal | official | The type of attestation the authenticator offers. | |
attester.time | When the composition was attested | When the composition was attested by the party. | |
attester.party | Who attested the composition | Who attested the composition in the specified way. | |
custodian | Organization which maintains the composition | Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. | 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 this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged. |
relatesTo | Relationships to other compositions/documents | Relationships that this composition has with other compositions or documents that already exist. | A document is a version specific composition. |
relatesTo.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
relatesTo.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
relatesTo.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
relatesTo.code | replaces | transforms | signs | appends | The type of relationship that this composition has with anther composition or document. | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. |
relatesTo.target[x] | Target of the relationship | The target composition/document of this relationship. | |
event | The clinical service(s) being documented | The clinical service, such as a colonoscopy or an appendectomy, being documented. | The event needs to be consistent with the type element, though can provide further information if desired. |
event.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
event.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
event.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
event.code | Code(s) that apply to the event being documented | 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. | 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. |
event.period | The period covered by the documentation | 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. | |
event.detail | The event(s) being documented | The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. | |
section | Composition is broken into sections | The root of the sections that make up the composition. | |
section.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
section.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
section.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
section.title | Label for section (e.g. for ToC) | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. |
section.code | Classification of section (recommended) | A code identifying the kind of content contained within the section. This must be consistent with the section title. | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
section.author | Who and/or what authored the section | Identifies who is responsible for the information in this section, not necessarily who typed it in. | |
section.focus | Who/what the section is about, when it is not about the subject of composition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. |
section.text | Text summary of the section, for human interpretation | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
section.mode | working | snapshot | changes | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. |
section.orderedBy | Order of section entries | Specifies the order applied to the items in the section entries. | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. |
section.entry | A reference to data that supports this section | A reference to the actual resource from which the narrative in the section is derived. | If there are no entries in the list, an emptyReason SHOULD be provided. |
section.emptyReason | Why the section is empty | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. |
section.section | Nested Section | A nested sub-section within this section. | Nested sections are primarily used to help human readers navigate to particular portions of the document. |
A Composition is the basic structure from which FHIR Documents - immutable bundles with attested narrative - are built. A single logical composition may be associated with a series of derived documents, each of which is a frozen copy of the composition.
Note: EN 13606 uses the term "Composition" to refer to a single commit to an EHR system, and offers some common examples: a composition containing a consultation note, a progress note, a report or a letter, an investigation report, a prescription form or a set of bedside nursing observations. Using Composition for an attested EHR commit is a valid use of the Composition resource, but for FHIR purposes, it would be usual to make more granular updates with individual provenance statements.
The CDA on FHIR profile constrains Composition to match CDA and specify a clinical document. See also the comparison with CDA.
Composition is a structure for grouping information for purposes of persistence and attestability. There are several other grouping structures in FHIR with distinct purposes:
The Composition resource organizes clinical and administrative content into sections, each of which contains a narrative, and references other resources for supporting data. The narrative content of the various sections in a Composition are supported by the resources referenced in the section entries. The complete set of content to make up a document includes the Composition resource together with various resources pointed to or indirectly connected to the Composition, all gathered together into a Bundle for transport and persistence. Resources associated with the following list of Composition references SHALL be included in the Bundle:
<%res-ref-list Composition%>Other resources referred to by those resources MAY be included in the Bundle at the discretion of the authoring system as documented in the system's operation definition (such as $document operation), or as specified by any applicable profiles.
Every composition has a status element, which describes the status of the content of the composition, taken from this list of codes:
<%codelist http://hl7.org/fhir/composition-status%>
Composition status generally only moves down through this list - it moves from preliminary
to final
and then it may progress to amended
.
Note that in many workflows, only final
compositions are made available and the preliminary
status is not used.
A very few compositions are created entirely in error in the workflow - usually the composition concerns the wrong patient or is written by the wrong author,
and the error is only detected after the composition has been used or documents have been derived from it. To support resolution of this case,
the composition is updated to be marked as entered-in-error
and a new derived document can be created. This means that the entire series of derived
documents is now considered to be created in error and systems receiving derived documents based on retracted compositions
SHOULD remove data taken from earlier documents from routine use and/or take other appropriate actions. Systems are not required to
provide this workflow or support documents derived from retracted compositions, but they SHALL NOT ignore a status of entered-in-error
.
Note that systems that handle compositions or derived documents and don't support the error status need to define
some other way of handling compositions that are created in error; while this is not a common occurrence, some clinical systems
have no provision for removing erroneous information from a patient's record, and there is no way for a user to know that it is not fit for use -
this is not safe.
Many users of this specification are familiar with the Clinical Document Architecture (CDA) and related specifications. CDA is a primary design input to the Composition resource (other principal inputs are other HL7 document specifications and EN13606). There are three important structural differences between CDA and the Composition resource:
Composition
(the confidentiality, subject, author, event, event period and encounter) apply to the composition and do not specifically apply to the resources referenced from
the section.entry
. There is no context flow model in FHIR, so each resource referenced from
within a Composition
expresses its own individual context. In this way, clinical content can
safely be extracted from the composition.In addition, note that both the code lists (e.g., Composition.status) and the Composition resource are mapped to HL7 v3 and/or CDA.
Composition.section.text
) and no entries (Composition.section.entry
)Typically, a composition is made about the subject - e.g. a patient, or group of patients, location, or device - and the distinction between the subject and the composition describes the subject. Some kinds of documents contain data about other parties or entities that are relevant to the subject of the document. Some examples:
In all these cases, the subject of the document is a single patient, but some of the details are actually
related to other persons or entities. When this happens, these other entities are detailed in the Composition.section.focus
element.
In the absence of a focus
, it is assumed that the subject
of the composition is the focus.
If a focus
is specified, then the resources referred to from the section SHALL
either:
subject
(however named e.g. patient
) or focus
element (if present) is the focus indicatedsubject
element
A few compositions genuinely cover multiple subjects - different sections are about different subjects. In such
case, Composition.subject
is omitted, and the extension section-subject
is used on each section to indicate the subject.
Feedback here. [%end-note%]
attester | Who attested the composition | Composition.attester.party |
author | Who and/or what authored the composition | Composition.author |
category | Categorization of Composition | Composition.category |
confidentiality | As defined by affinity domain | Composition.confidentiality |
context | Code(s) that apply to the event being documented | Composition.event.code |
encounter | Multiple Resources: * [Composition](composition.html): Context of the Composition * [DeviceRequest](devicerequest.html): Encounter during which request was created * [DiagnosticReport](diagnosticreport.html): The Encounter when the order was made * [DocumentReference](documentreference.html): Context of the document content * [Flag](flag.html): Alert relevant during encounter * [List](list.html): Context in which list created * [NutritionOrder](nutritionorder.html): Return nutrition orders with this encounter identifier * [Observation](observation.html): Encounter related to the observation * [Procedure](procedure.html): Encounter created as part of * [RiskAssessment](riskassessment.html): Where was assessment performed? * [ServiceRequest](servicerequest.html): An encounter in which this request is made * [VisionPrescription](visionprescription.html): Return prescriptions with this encounter identifier | Composition.encounter | DeviceRequest.encounter | DiagnosticReport.encounter | DocumentReference.context.encounter | Flag.encounter | List.encounter | NutritionOrder.encounter | Observation.encounter | Procedure.encounter | RiskAssessment.context.where(resolve() is Encounter) | ServiceRequest.encounter | VisionPrescription.encounter |
entry | A reference to data that supports this section | Composition.section.entry |
period | The period covered by the documentation | Composition.event.period |
related-id | Target of the relationship | (Composition.relatesTo.target as Identifier) |
related-ref | Target of the relationship | (Composition.relatesTo.target as Reference) |
section | Classification of section (recommended) | Composition.section.code |
status | preliminary | final | amended | entered-in-error | Composition.status |
subject | Who and/or what the composition is about | Composition.subject |
title | Human Readable name/title | Composition.title |
The CDA-in-FHIR profile constrains Composition to match CDA and specify a clinical document. 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
Path | Short | Definition | Comments |
---|---|---|---|
A set of resources composed into a single coherent clinical statement with clinical attestation | A set of healthcare-related information that is assembled together into a single logical package 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. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). | 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. | |
identifier | Version-independent identifier for the Composition | A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time. | Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate. |
status | preliminary | final | amended | entered-in-error | The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. | 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 "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. |
type | Kind of composition (LOINC if possible) | 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. | For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. |
category | Categorization of Composition | A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type. | This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)). |
subject | Who and/or what the composition is about | Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a 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). | For clinical documents, this is usually the patient. |
encounter | Context of the Composition | Describes the clinical encounter or type of care this documentation is associated with. | |
date | Composition editing time | The composition editing time, when the composition was last logically changed by the author. | The Last Modified Date on the composition may be after the date of the document was attested without being changed. |
author | Who and/or what authored the composition | Identifies who is responsible for the information in the composition, not necessarily who typed it in. | |
title | Human Readable name/title | Official human-readable label for the composition. | For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period. |
confidentiality | As defined by affinity domain | The code specifying the level of confidentiality of the Composition. | The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. |
attester | Attests to accuracy of composition | A participant who has attested to the accuracy of the composition/document. | Only list each attester once. |
attester.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
attester.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
attester.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
attester.mode | personal | professional | legal | official | The type of attestation the authenticator offers. | |
attester.time | When the composition was attested | When the composition was attested by the party. | |
attester.party | Who attested the composition | Who attested the composition in the specified way. | |
custodian | Organization which maintains the composition | Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. | 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 this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged. |
relatesTo | Relationships to other compositions/documents | Relationships that this composition has with other compositions or documents that already exist. | A document is a version specific composition. |
relatesTo.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
relatesTo.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
relatesTo.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
relatesTo.code | replaces | transforms | signs | appends | The type of relationship that this composition has with anther composition or document. | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. |
relatesTo.target[x] | Target of the relationship | The target composition/document of this relationship. | |
event | The clinical service(s) being documented | The clinical service, such as a colonoscopy or an appendectomy, being documented. | The event needs to be consistent with the type element, though can provide further information if desired. |
event.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
event.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
event.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
event.code | Code(s) that apply to the event being documented | 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. | 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. |
event.period | The period covered by the documentation | 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. | |
event.detail | The event(s) being documented | The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. | |
section | Composition is broken into sections | The root of the sections that make up the composition. | |
section.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
section.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
section.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
section.title | Label for section (e.g. for ToC) | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. |
section.code | Classification of section (recommended) | A code identifying the kind of content contained within the section. This must be consistent with the section title. | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
section.author | Who and/or what authored the section | Identifies who is responsible for the information in this section, not necessarily who typed it in. | |
section.focus | Who/what the section is about, when it is not about the subject of composition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. |
section.text | Text summary of the section, for human interpretation | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
section.mode | working | snapshot | changes | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. |
section.orderedBy | Order of section entries | Specifies the order applied to the items in the section entries. | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. |
section.entry | A reference to data that supports this section | A reference to the actual resource from which the narrative in the section is derived. | If there are no entries in the list, an emptyReason SHOULD be provided. |
section.emptyReason | Why the section is empty | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. |
section.section | Nested Section | A nested sub-section within this section. | Nested sections are primarily used to help human readers navigate to particular portions of the document. |
A set of resources composed into a single coherent clinical statement with clinical attestation
Path | Short | Definition | Comments |
---|---|---|---|
A set of resources composed into a single coherent clinical statement with clinical attestation | 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. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained. | 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. | |
identifier | Version-independent identifier for the Composition | A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time. | Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate. |
status | preliminary | final | amended | entered-in-error | The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. | 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 "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. |
type | The type of document - a Catalog | The type of document - a Catalog. | For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. |
category | The Content of the section | The content (narrative and data) associated with the section. | This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)). |
subject | Who and/or what the composition is about | Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a 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). | For clinical documents, this is usually the patient. |
encounter | Context of the Composition | Describes the clinical encounter or type of care this documentation is associated with. | |
date | When the Catalog was created | When the Catalog was created. | The Last Modified Date on the composition may be after the date of the document was attested without being changed. |
author | Who and/or what authored the composition | Identifies who is responsible for the information in the composition, not necessarily who typed it in. | |
title | Human Readable name/title | Official human-readable label for the composition. | For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period. |
confidentiality | As defined by affinity domain | The code specifying the level of confidentiality of the Composition. | The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. |
attester | Attests to accuracy of composition | A participant who has attested to the accuracy of the composition/document. | Only list each attester once. |
attester.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
attester.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
attester.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
attester.mode | personal | professional | legal | official | The type of attestation the authenticator offers. | |
attester.time | When the composition was attested | When the composition was attested by the party. | |
attester.party | Who attested the composition | Who attested the composition in the specified way. | |
custodian | Organization which maintains the composition | Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. | 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 this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged. |
relatesTo | Relationships to other compositions/documents | Relationships that this composition has with other compositions or documents that already exist. | A document is a version specific composition. |
relatesTo.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
relatesTo.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
relatesTo.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
relatesTo.code | replaces | transforms | signs | appends | The type of relationship that this composition has with anther composition or document. | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. |
relatesTo.target[x] | Target of the relationship | The target composition/document of this relationship. | |
event | The clinical service(s) being documented | The clinical service, such as a colonoscopy or an appendectomy, being documented. | The event needs to be consistent with the type element, though can provide further information if desired. |
event.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
event.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
event.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
event.code | Code(s) that apply to the event being documented | 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. | 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. |
event.period | The period covered by the documentation | 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. | |
event.detail | The event(s) being documented | The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. | |
section | Composition is broken into sections | The root of the sections that make up the composition. | |
section.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
section.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
section.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
section.title | Label for section (e.g. for ToC) | The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. | The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. |
section.code | Classification of section (recommended) | A code identifying the kind of content contained within the section. This must be consistent with the section title. | The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. |
section.author | Who and/or what authored the section | Identifies who is responsible for the information in this section, not necessarily who typed it in. | |
section.focus | Who/what the section is about, when it is not about the subject of composition | The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). | Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples. |
section.text | Text summary of the section, for human interpretation | A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. | Document profiles may define what content should be represented in the narrative to ensure clinical safety. |
section.mode | working | snapshot | changes | How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. | This element is labeled as a modifier because a change list must not be misunderstood as a complete list. |
section.orderedBy | Order of section entries | Specifies the order applied to the items in the section entries. | Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. |
section.entry | The Content of the section | The content (narrative and data) associated with the section. | If there are no entries in the list, an emptyReason SHOULD be provided. |
section.emptyReason | Why the section is empty | If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. | The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. |
section.section | Nested Section | A nested sub-section within this section. | Nested sections are primarily used to help human readers navigate to particular portions of the document. |