StandardPatientHealthRecordIG - Local Development build (v0.4.4). See the Directory of published versions
Resource Profile: PhrComposition
| Official URL: https://open-health-manager.github.io/standard-patient-health-record-ig/StructureDefinition/PhrComposition | Version: 0.4.4 | |||
| Active as of 2023-03-03 | Computable Name: PhrComposition | |||
Standard PHR profile of the Composition resource.
Usage:
- This Resource Profile is not used by any profiles in this Implementation Guide
Formal Views of Profile Content
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  type | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Required Pattern: At least the following | |
   coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
  system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11503-0 | |
 display | 1..1 | string | Representation defined by the system Fixed Value: Medical records | |
| subject | S | 1..1 | Reference(Resource) | Who and/or what the composition is about |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
 type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11503-0 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Medical records | |
 subject | SΣ | 1..1 | Reference(Resource) | Who and/or what the composition is about |
| date | Σ | 1..1 | dateTime | Composition editing time |
| author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
| title | Σ | 1..1 | string | Human Readable name/title |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet / Code |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | Pattern: LOINC code 11503-0("Medical records") |
Constraints
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11503-0 | |||||
| display | 1..1 | string | Representation defined by the system Fixed Value: Medical records | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 1..1 | Reference(Resource) | Who and/or what the composition is about | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
| date | Σ | 1..1 | dateTime | Composition editing time | ||||
| author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition | ||||
| title | Σ | 1..1 | string | Human Readable name/title | ||||
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
 target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| section | C | 0..* | BackboneElement | Composition is broken into sections | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (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..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
Terminology Bindings
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | Pattern: LOINC code 11503-0("Medical records") | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons |
Constraints
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| type | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11503-0 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Medical records | |
| subject | S | 1..1 | Reference(Resource) | Who and/or what the composition is about |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11503-0 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Medical records | |
| subject | SΣ | 1..1 | Reference(Resource) | Who and/or what the composition is about |
| date | Σ | 1..1 | dateTime | Composition editing time |
| author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
| title | Σ | 1..1 | string | Human Readable name/title |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet / Code |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | Pattern: LOINC code 11503-0("Medical records") |
Constraints
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11503-0 | |||||
| display | 1..1 | string | Representation defined by the system Fixed Value: Medical records | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 1..1 | Reference(Resource) | Who and/or what the composition is about | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
| date | Σ | 1..1 | dateTime | Composition editing time | ||||
| author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition | ||||
| title | Σ | 1..1 | string | Human Readable name/title | ||||
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| section | C | 0..* | BackboneElement | Composition is broken into sections | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (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..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
Terminology Bindings
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | Pattern: LOINC code 11503-0("Medical records") | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons |
Constraints
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Other representations of profile: CSV, Excel, Schematron