Aged Care Clinical Note - Local Development build (v0.1.0-preview) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: AU Aged Care Clinical Note - Composition

Official URL: http://ns.electronichealth.net.au/fhir/cn/StructureDefinition/au-aged-care-clin-note-composition Version: 0.1.0-preview
Standards status: Draft Maturity Level: 0 Computable Name: AUAgedCareClinNoteComposition

Usage:Jurisdiction: Australia

Copyright/Legal: Copyright © 2025 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/.

This profile specialises the FHIR Clinical Document Composition Profile for the purposes of an Aged Care Clinical Note in Australia. All the guidelines and conformance requirements defined of the FHIR Clinical Document Composition apply.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* ClinicalDocumentComposition Australian Aged Care Clinical Note Composition
Constraints: clindoc-limit-participantType, NarrativeOrMedicationsSection, NarrativeTextOrEntry
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language S 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text S 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... extension:R5-Composition-version S 0..1 string Optional Extensions Element
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
.... extension:data-enterer S 0..1 (Complex) A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension
.... extension:informant S 0..* (Complex) An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension
.... extension:information-recipient S 1..* (Complex) Information Recipient Extension
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension
..... Slices for extension 2..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:type 1..* Extension Extension
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "type"
....... value[x] 1..1 CodeableConcept Value of extension
Binding: Information Recipient Type (required)
...... extension:function 0..* Extension Exact function of the participant in the creation of the clinical document. This is more granular than type.
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "function"
....... value[x] 1..1 CodeableConcept Value of extension
Binding: ParticipationFunction (3.0.0) (extensible)
...... extension:time 0..1 Extension Time period of participation
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "time"
....... value[x] 1..1 Period Value of extension
...... extension:party S 1..1 Extension Extension
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "party"
....... value[x] 1..1 Reference(AU Aged Care Clinical Note - Organization | AU Aged Care Clinical Note - Department | AU Aged Care Clinical Note - PractitionerRole) If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organisation profile.
..... url 1..1 uri "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension"
.... extension:participant S 0..* (Complex) A Participant that is not a data-enter, information-recipient nor an informant
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension
.... extension:consent S 0..* Reference(Consent) consent
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension
.... extension:basedOn S 0..* Reference(Resource) The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray.
URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
.... extension:change-made S 0..1 (Complex) Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
... Slices for modifierExtension ?! 0..* Extension Extension
Slice: Unordered, Open by value:url
.... modifierExtension:R5-Composition-status ?!S 0..1 base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status
... identifier SΣ 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 SΣ 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: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.32054
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... Slices for category SΣ 1..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by value:text
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:clinicalnotecategory SΣ 1..1 CodeableConcept Category for Clinical Note
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.

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: 107903-7
...... display 1..1 string Representation defined by the system
Fixed Value: Clinical note
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
..... text Σ 1..1 string Plain text representation of the concept
Required Pattern: Clinical Note
.... category:agedCareClinicalNoteCategory SΣ 0..1 CodeableConcept Aged Care Clinical Note
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
..... coding Σ 0..* Coding Code defined by a terminology system

Required Pattern: At least the following
...... 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: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.32053
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text Σ 1..1 string Plain text representation of the concept
Required Pattern: Aged and Residential Care Clinical Document
... subject SΣ 1..1 Reference(AU Aged Care Clinical Note - Patient) Who and/or what the composition is about
... date SΣ 1..1 dateTime Composition editing time
... author SΣ 1..1 Reference(AU Aged Care Clinical Note - Organization | AU Aged Care Clinical Note - PractitionerRole) If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organisation profile.
... title SΣ 1..1 string Human Readable name/title
... Slices for attester S 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
..... time S 0..1 dateTime When the composition was attested
..... party S 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
.... attester:legal_attester S 0..1 BackboneElement aka legal authenticator
..... 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.
Required Pattern: legal
.... attester:professional_attester S 0..* BackboneElement aka authenticator
..... 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.
Required Pattern: professional
... custodian SΣ 0..1 Reference(AU Aged Care Clinical Note - Organization) Organization which maintains the composition
... Slices for relatesTo S 0..* BackboneElement Relationships to other compositions/documents
Slice: Unordered, Open by value:code, type:target
.... relatesTo:All Slices Content/Rules for all slices
..... 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.
..... Slices for target[x] 1..1 Target of the relationship
Slice: Unordered, Open by type:$this
...... targetIdentifier Identifier
...... targetReference Reference(Composition)
...... target[x]:targetIdentifier 0..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document
.... relatesTo:replaced_document S 0..* BackboneElement The document(s) being superceded
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Required Pattern: replaces
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
...... target[x]:targetIdentifier 1..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document
....... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
....... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
....... value Σ 1..1 string The value that is unique
Example General: 123456
.... relatesTo:appended_document S 0..* BackboneElement The document(s) being appended too
..... 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.
Required Pattern: appends
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
...... target[x]:targetIdentifier 1..1 Identifier Target of the relationship
....... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
... Slices for section SC 1..* BackboneElement Sections composing the aged care clinical note
Slice: Unordered, Open by pattern:code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... Slices for extension Content/Rules for all slices
...... extension:change-made S 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Label for section (e.g. for ToC)
..... code S 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... text SC 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:sectionNarrative SC 0..1 BackboneElement Narrative Section
Constraints: cmp-1, cmp-2
..... Slices for extension Content/Rules for all slices
...... extension:change-made S 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Label for section (e.g. for ToC)
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
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: 61149-1
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text SC 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(DocumentReference) Attachments that are relevant to this section.
Slice: Unordered, Open by profile:resolve()
...... entry:attachment SC 0..* Reference(AU Aged Care Clinical Note - DocumentReference) A reference to data that supports this section
.... section:sectionMedications SC 0..1 BackboneElement Medications Section
Constraints: cmp-1, cmp-2
..... Slices for extension Content/Rules for all slices
...... extension:change-made S 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Label for section (e.g. for ToC)
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
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: 10160-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(MedicationStatement) Medication statements that are relevant to this section.
Slice: Unordered, Open by profile:resolve()
...... entry:medicationStatement SC 0..* Reference(AU Aged Care Clinical Note - MedicationStatement) A reference to data that supports this section

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Composition.extension:information-recipient.​extension:type.value[x] Base required Information Recipient Type 📦0.1.0-preview This IG
Composition.extension:information-recipient.​extension:function.value[x] Base extensible ParticipationFunction 📍3.0.0 THO v7.0
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📦4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.category:clinicalnotecategory Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.category:agedCareClinicalNoteCategory Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legal_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:professional_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.section.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:sectionNarrative.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:sectionMedications.​code Base example Document Section Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
NarrativeOrMedicationsSection error Composition Composition must have either a sectionNarrative or a sectionMedications section. section.where(code.coding.code = '61149-1').exists() or section.where(code.coding.code = '10160-0').exists()
NarrativeTextOrEntry error Composition section[sectionNarrative] must have either text or at least one entry with a DocumentReference. section.where(code.coding.code = '61149-1').all(text.exists() or entry.resolve().ofType(DocumentReference).exists())
clindoc-limit-participantType error Composition The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()
cmp-1 error Composition.section, Composition.section:sectionNarrative, Composition.section:sectionMedications 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, Composition.section:sectionNarrative, Composition.section:sectionMedications A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
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()

This structure is derived from ClinicalDocumentComposition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* ClinicalDocumentComposition Australian Aged Care Clinical Note Composition
Constraints: NarrativeOrMedicationsSection, NarrativeTextOrEntry
... extension 1..* Extension Extension
... Slices for extension Content/Rules for all slices
.... extension:information-recipient 1..* InformationRecipientExtension Information Recipient Extension
..... Slices for extension Content/Rules for all slices
...... extension:type 1..* Extension Extension
....... value[x] 1..1 CodeableConcept Value of extension
Binding: Information Recipient Type (required)
...... extension:party 1..1 Extension Extension
....... value[x] 1..1 Reference(AU Aged Care Clinical Note - Organization | AU Aged Care Clinical Note - Department | AU Aged Care Clinical Note - PractitionerRole) If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organisation profile.
... 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: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.32054
.... category:clinicalnotecategory 1..1 CodeableConcept Category for Clinical Note
..... text 1..1 string Plain text representation of the concept
Required Pattern: Clinical Note
.... category:agedCareClinicalNoteCategory S 0..1 CodeableConcept Aged Care Clinical Note
..... coding 0..* Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.32053
..... text 1..1 string Plain text representation of the concept
Required Pattern: Aged and Residential Care Clinical Document
... subject 1..1 Reference(AU Aged Care Clinical Note - Patient) Who and/or what the composition is about
... author 1..1 Reference(AU Aged Care Clinical Note - Organization | AU Aged Care Clinical Note - PractitionerRole) If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organisation profile.
... custodian 0..1 Reference(AU Aged Care Clinical Note - Organization) Organization which maintains the composition
... Slices for section 1..* BackboneElement Sections composing the aged care clinical note
Slice: Unordered, Open by pattern:code
.... section:All Slices Content/Rules for all slices
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
.... section:sectionNarrative S 0..1 BackboneElement Narrative Section
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 ChangeMade Change Made
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
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: 61149-1
..... Slices for entry 0..* Reference(DocumentReference) Attachments that are relevant to this section.
Slice: Unordered, Open by profile:resolve()
...... entry:attachment S 0..* Reference(AU Aged Care Clinical Note - DocumentReference) A reference to data that supports this section
.... section:sectionMedications S 0..1 BackboneElement Medications Section
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 ChangeMade Change Made
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
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: 10160-0
..... text 1..1 Narrative Text summary of the section, for human interpretation
..... Slices for entry 0..* Reference(MedicationStatement) Medication statements that are relevant to this section.
Slice: Unordered, Open by profile:resolve()
...... entry:medicationStatement S 0..* Reference(AU Aged Care Clinical Note - MedicationStatement) A reference to data that supports this section

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Composition.extension:information-recipient.​extension:type.value[x] Base required Information Recipient Type 📦0.1.0-preview This IG

Constraints

Id Grade Path(s) Description Expression
NarrativeOrMedicationsSection error Composition Composition must have either a sectionNarrative or a sectionMedications section. section.where(code.coding.code = '61149-1').exists() or section.where(code.coding.code = '10160-0').exists()
NarrativeTextOrEntry error Composition section[sectionNarrative] must have either text or at least one entry with a DocumentReference. section.where(code.coding.code = '61149-1').all(text.exists() or entry.resolve().ofType(DocumentReference).exists())
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* ClinicalDocumentComposition Australian Aged Care Clinical Note Composition
Constraints: clindoc-limit-participantType, NarrativeOrMedicationsSection, NarrativeTextOrEntry
... 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
... text S 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:R5-Composition-version S 0..1 string Optional Extensions Element
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
.... extension:data-enterer S 0..1 (Complex) A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension
.... extension:informant S 0..* (Complex) An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension
.... extension:information-recipient S 1..* (Complex) Information Recipient Extension
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 2..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:type 1..* Extension Extension
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "type"
....... value[x] 1..1 CodeableConcept Value of extension
Binding: Information Recipient Type (required)
...... extension:function 0..* Extension Exact function of the participant in the creation of the clinical document. This is more granular than type.
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "function"
....... value[x] 1..1 CodeableConcept Value of extension
Binding: ParticipationFunction (3.0.0) (extensible)
...... extension:time 0..1 Extension Time period of participation
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "time"
....... value[x] 1..1 Period Value of extension
...... extension:party S 1..1 Extension Extension
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "party"
....... value[x] 1..1 Reference(AU Aged Care Clinical Note - Organization | AU Aged Care Clinical Note - Department | AU Aged Care Clinical Note - PractitionerRole) If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organisation profile.
..... url 1..1 uri "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension"
.... extension:participant S 0..* (Complex) A Participant that is not a data-enter, information-recipient nor an informant
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension
.... extension:consent S 0..* Reference(Consent) consent
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension
.... extension:basedOn S 0..* Reference(Resource) The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray.
URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
.... extension:change-made S 0..1 (Complex) Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
... Slices for modifierExtension ?! 0..* Extension Extension
Slice: Unordered, Open by value:url
.... modifierExtension:R5-Composition-status ?!S 0..1 base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status
... identifier SΣ 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 SΣ 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: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.32054
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... Slices for category SΣ 1..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by value:text
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:clinicalnotecategory SΣ 1..1 CodeableConcept Category for Clinical Note
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.

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: 107903-7
...... display 1..1 string Representation defined by the system
Fixed Value: Clinical note
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system
..... text Σ 1..1 string Plain text representation of the concept
Required Pattern: Clinical Note
.... category:agedCareClinicalNoteCategory SΣ 0..1 CodeableConcept Aged Care Clinical Note
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system

Required Pattern: At least the following
...... 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: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.32053
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text Σ 1..1 string Plain text representation of the concept
Required Pattern: Aged and Residential Care Clinical Document
... subject SΣ 1..1 Reference(AU Aged Care Clinical Note - Patient) Who and/or what the composition is about
... encounter Σ 0..1 Reference(Encounter) Context of the Composition
... date SΣ 1..1 dateTime Composition editing time
... author SΣ 1..1 Reference(AU Aged Care Clinical Note - Organization | AU Aged Care Clinical Note - PractitionerRole) If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organisation profile.
... title SΣ 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.
... Slices for attester S 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... 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 S 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
..... time S 0..1 dateTime When the composition was attested
..... party S 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
.... attester:legal_attester S 0..1 BackboneElement aka legal authenticator
..... 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.
Required Pattern: legal
..... time 0..1 dateTime When the composition was attested
..... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
.... attester:professional_attester S 0..* BackboneElement aka authenticator
..... 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.
Required Pattern: professional
..... time 0..1 dateTime When the composition was attested
..... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
... custodian SΣ 0..1 Reference(AU Aged Care Clinical Note - Organization) Organization which maintains the composition
... Slices for relatesTo S 0..* BackboneElement Relationships to other compositions/documents
Slice: Unordered, Open by value:code, type:target
.... relatesTo:All Slices Content/Rules for all slices
..... 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.
..... Slices for target[x] 1..1 Target of the relationship
Slice: Unordered, Open by type:$this
...... targetIdentifier Identifier
...... targetReference Reference(Composition)
...... target[x]:targetIdentifier 0..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document
.... relatesTo:replaced_document S 0..* BackboneElement The document(s) being superceded
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Required Pattern: replaces
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
...... target[x]:targetIdentifier 1..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
....... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
....... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
....... value Σ 1..1 string The value that is unique
Example General: 123456
....... period Σ 0..1 Period Time period when id is/was valid for use
....... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... relatesTo:appended_document S 0..* BackboneElement The document(s) being appended too
..... 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.
Required Pattern: appends
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
...... target[x]:targetIdentifier 1..1 Identifier Target of the relationship
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
....... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
....... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
....... value Σ 0..1 string The value that is unique
Example General: 123456
....... period Σ 0..1 Period Time period when id is/was valid for use
....... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... 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: ActCode (3.0.0) (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
... Slices for section SC 1..* BackboneElement Sections composing the aged care clinical note
Slice: Unordered, Open by pattern:code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:change-made S 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Label for section (e.g. for ToC)
..... code S 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 SC 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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
.... section:sectionNarrative SC 0..1 BackboneElement Narrative Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:change-made S 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Label for section (e.g. for ToC)
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
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: 61149-1
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... 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 SC 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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.
..... Slices for entry C 0..* Reference(DocumentReference) Attachments that are relevant to this section.
Slice: Unordered, Open by profile:resolve()
...... entry:attachment SC 0..* Reference(AU Aged Care Clinical Note - DocumentReference) 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
.... section:sectionMedications SC 0..1 BackboneElement Medications Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:change-made S 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Label for section (e.g. for ToC)
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
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: 10160-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... 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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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.
..... Slices for entry C 0..* Reference(MedicationStatement) Medication statements that are relevant to this section.
Slice: Unordered, Open by profile:resolve()
...... entry:medicationStatement SC 0..* Reference(AU Aged Care Clinical Note - MedicationStatement) 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Composition.extension:information-recipient.​extension:type.value[x] Base required Information Recipient Type 📦0.1.0-preview This IG
Composition.extension:information-recipient.​extension:function.value[x] Base extensible ParticipationFunction 📍3.0.0 THO v7.0
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📦4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.category:clinicalnotecategory Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.category:agedCareClinicalNoteCategory Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legal_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:professional_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
Composition.event.code Base example v3 Code System ActCode 📍3.0.0 THO v7.0
Composition.section.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:sectionNarrative.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:sectionNarrative.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionNarrative.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:sectionNarrative.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:sectionMedications.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:sectionMedications.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:sectionMedications.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
NarrativeOrMedicationsSection error Composition Composition must have either a sectionNarrative or a sectionMedications section. section.where(code.coding.code = '61149-1').exists() or section.where(code.coding.code = '10160-0').exists()
NarrativeTextOrEntry error Composition section[sectionNarrative] must have either text or at least one entry with a DocumentReference. section.where(code.coding.code = '61149-1').all(text.exists() or entry.resolve().ofType(DocumentReference).exists())
clindoc-limit-participantType error Composition The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()
cmp-1 error Composition.section, Composition.section:sectionNarrative, Composition.section:sectionMedications 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, Composition.section:sectionNarrative, Composition.section:sectionMedications A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
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()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* ClinicalDocumentComposition Australian Aged Care Clinical Note Composition
Constraints: clindoc-limit-participantType, NarrativeOrMedicationsSection, NarrativeTextOrEntry
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language S 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text S 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... extension:R5-Composition-version S 0..1 string Optional Extensions Element
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
.... extension:data-enterer S 0..1 (Complex) A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension
.... extension:informant S 0..* (Complex) An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension
.... extension:information-recipient S 1..* (Complex) Information Recipient Extension
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension
..... Slices for extension 2..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:type 1..* Extension Extension
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "type"
....... value[x] 1..1 CodeableConcept Value of extension
Binding: Information Recipient Type (required)
...... extension:function 0..* Extension Exact function of the participant in the creation of the clinical document. This is more granular than type.
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "function"
....... value[x] 1..1 CodeableConcept Value of extension
Binding: ParticipationFunction (3.0.0) (extensible)
...... extension:time 0..1 Extension Time period of participation
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "time"
....... value[x] 1..1 Period Value of extension
...... extension:party S 1..1 Extension Extension
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "party"
....... value[x] 1..1 Reference(AU Aged Care Clinical Note - Organization | AU Aged Care Clinical Note - Department | AU Aged Care Clinical Note - PractitionerRole) If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organisation profile.
..... url 1..1 uri "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension"
.... extension:participant S 0..* (Complex) A Participant that is not a data-enter, information-recipient nor an informant
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension
.... extension:consent S 0..* Reference(Consent) consent
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension
.... extension:basedOn S 0..* Reference(Resource) The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray.
URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
.... extension:change-made S 0..1 (Complex) Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
... Slices for modifierExtension ?! 0..* Extension Extension
Slice: Unordered, Open by value:url
.... modifierExtension:R5-Composition-status ?!S 0..1 base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status
... identifier SΣ 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 SΣ 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: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.32054
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... Slices for category SΣ 1..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by value:text
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:clinicalnotecategory SΣ 1..1 CodeableConcept Category for Clinical Note
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.

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: 107903-7
...... display 1..1 string Representation defined by the system
Fixed Value: Clinical note
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
..... text Σ 1..1 string Plain text representation of the concept
Required Pattern: Clinical Note
.... category:agedCareClinicalNoteCategory SΣ 0..1 CodeableConcept Aged Care Clinical Note
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
..... coding Σ 0..* Coding Code defined by a terminology system

Required Pattern: At least the following
...... 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: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.32053
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text Σ 1..1 string Plain text representation of the concept
Required Pattern: Aged and Residential Care Clinical Document
... subject SΣ 1..1 Reference(AU Aged Care Clinical Note - Patient) Who and/or what the composition is about
... date SΣ 1..1 dateTime Composition editing time
... author SΣ 1..1 Reference(AU Aged Care Clinical Note - Organization | AU Aged Care Clinical Note - PractitionerRole) If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organisation profile.
... title SΣ 1..1 string Human Readable name/title
... Slices for attester S 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode S 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
..... time S 0..1 dateTime When the composition was attested
..... party S 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
.... attester:legal_attester S 0..1 BackboneElement aka legal authenticator
..... 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.
Required Pattern: legal
.... attester:professional_attester S 0..* BackboneElement aka authenticator
..... 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.
Required Pattern: professional
... custodian SΣ 0..1 Reference(AU Aged Care Clinical Note - Organization) Organization which maintains the composition
... Slices for relatesTo S 0..* BackboneElement Relationships to other compositions/documents
Slice: Unordered, Open by value:code, type:target
.... relatesTo:All Slices Content/Rules for all slices
..... 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.
..... Slices for target[x] 1..1 Target of the relationship
Slice: Unordered, Open by type:$this
...... targetIdentifier Identifier
...... targetReference Reference(Composition)
...... target[x]:targetIdentifier 0..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document
.... relatesTo:replaced_document S 0..* BackboneElement The document(s) being superceded
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Required Pattern: replaces
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
...... target[x]:targetIdentifier 1..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document
....... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
....... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
....... value Σ 1..1 string The value that is unique
Example General: 123456
.... relatesTo:appended_document S 0..* BackboneElement The document(s) being appended too
..... 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.
Required Pattern: appends
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
...... target[x]:targetIdentifier 1..1 Identifier Target of the relationship
....... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
... Slices for section SC 1..* BackboneElement Sections composing the aged care clinical note
Slice: Unordered, Open by pattern:code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... Slices for extension Content/Rules for all slices
...... extension:change-made S 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Label for section (e.g. for ToC)
..... code S 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
..... text SC 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section:sectionNarrative SC 0..1 BackboneElement Narrative Section
Constraints: cmp-1, cmp-2
..... Slices for extension Content/Rules for all slices
...... extension:change-made S 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Label for section (e.g. for ToC)
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
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: 61149-1
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text SC 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(DocumentReference) Attachments that are relevant to this section.
Slice: Unordered, Open by profile:resolve()
...... entry:attachment SC 0..* Reference(AU Aged Care Clinical Note - DocumentReference) A reference to data that supports this section
.... section:sectionMedications SC 0..1 BackboneElement Medications Section
Constraints: cmp-1, cmp-2
..... Slices for extension Content/Rules for all slices
...... extension:change-made S 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Label for section (e.g. for ToC)
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
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: 10160-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... text SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... Slices for entry C 0..* Reference(MedicationStatement) Medication statements that are relevant to this section.
Slice: Unordered, Open by profile:resolve()
...... entry:medicationStatement SC 0..* Reference(AU Aged Care Clinical Note - MedicationStatement) A reference to data that supports this section

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Composition.extension:information-recipient.​extension:type.value[x] Base required Information Recipient Type 📦0.1.0-preview This IG
Composition.extension:information-recipient.​extension:function.value[x] Base extensible ParticipationFunction 📍3.0.0 THO v7.0
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📦4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.category:clinicalnotecategory Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.category:agedCareClinicalNoteCategory Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legal_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:professional_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.section.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:sectionNarrative.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:sectionMedications.​code Base example Document Section Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
NarrativeOrMedicationsSection error Composition Composition must have either a sectionNarrative or a sectionMedications section. section.where(code.coding.code = '61149-1').exists() or section.where(code.coding.code = '10160-0').exists()
NarrativeTextOrEntry error Composition section[sectionNarrative] must have either text or at least one entry with a DocumentReference. section.where(code.coding.code = '61149-1').all(text.exists() or entry.resolve().ofType(DocumentReference).exists())
clindoc-limit-participantType error Composition The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()
cmp-1 error Composition.section, Composition.section:sectionNarrative, Composition.section:sectionMedications 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, Composition.section:sectionNarrative, Composition.section:sectionMedications A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
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()

Differential View

This structure is derived from ClinicalDocumentComposition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* ClinicalDocumentComposition Australian Aged Care Clinical Note Composition
Constraints: NarrativeOrMedicationsSection, NarrativeTextOrEntry
... extension 1..* Extension Extension
... Slices for extension Content/Rules for all slices
.... extension:information-recipient 1..* InformationRecipientExtension Information Recipient Extension
..... Slices for extension Content/Rules for all slices
...... extension:type 1..* Extension Extension
....... value[x] 1..1 CodeableConcept Value of extension
Binding: Information Recipient Type (required)
...... extension:party 1..1 Extension Extension
....... value[x] 1..1 Reference(AU Aged Care Clinical Note - Organization | AU Aged Care Clinical Note - Department | AU Aged Care Clinical Note - PractitionerRole) If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organisation profile.
... 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: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.32054
.... category:clinicalnotecategory 1..1 CodeableConcept Category for Clinical Note
..... text 1..1 string Plain text representation of the concept
Required Pattern: Clinical Note
.... category:agedCareClinicalNoteCategory S 0..1 CodeableConcept Aged Care Clinical Note
..... coding 0..* Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.32053
..... text 1..1 string Plain text representation of the concept
Required Pattern: Aged and Residential Care Clinical Document
... subject 1..1 Reference(AU Aged Care Clinical Note - Patient) Who and/or what the composition is about
... author 1..1 Reference(AU Aged Care Clinical Note - Organization | AU Aged Care Clinical Note - PractitionerRole) If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organisation profile.
... custodian 0..1 Reference(AU Aged Care Clinical Note - Organization) Organization which maintains the composition
... Slices for section 1..* BackboneElement Sections composing the aged care clinical note
Slice: Unordered, Open by pattern:code
.... section:All Slices Content/Rules for all slices
..... Slices for extension Content/Rules for all slices
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
.... section:sectionNarrative S 0..1 BackboneElement Narrative Section
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 ChangeMade Change Made
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
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: 61149-1
..... Slices for entry 0..* Reference(DocumentReference) Attachments that are relevant to this section.
Slice: Unordered, Open by profile:resolve()
...... entry:attachment S 0..* Reference(AU Aged Care Clinical Note - DocumentReference) A reference to data that supports this section
.... section:sectionMedications S 0..1 BackboneElement Medications Section
..... Slices for extension Content/Rules for all slices
...... extension:change-made 0..1 ChangeMade Change Made
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... code 1..1 CodeableConcept Classification of section (recommended)
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: 10160-0
..... text 1..1 Narrative Text summary of the section, for human interpretation
..... Slices for entry 0..* Reference(MedicationStatement) Medication statements that are relevant to this section.
Slice: Unordered, Open by profile:resolve()
...... entry:medicationStatement S 0..* Reference(AU Aged Care Clinical Note - MedicationStatement) A reference to data that supports this section

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Composition.extension:information-recipient.​extension:type.value[x] Base required Information Recipient Type 📦0.1.0-preview This IG

Constraints

Id Grade Path(s) Description Expression
NarrativeOrMedicationsSection error Composition Composition must have either a sectionNarrative or a sectionMedications section. section.where(code.coding.code = '61149-1').exists() or section.where(code.coding.code = '10160-0').exists()
NarrativeTextOrEntry error Composition section[sectionNarrative] must have either text or at least one entry with a DocumentReference. section.where(code.coding.code = '61149-1').all(text.exists() or entry.resolve().ofType(DocumentReference).exists())

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition C 0..* ClinicalDocumentComposition Australian Aged Care Clinical Note Composition
Constraints: clindoc-limit-participantType, NarrativeOrMedicationsSection, NarrativeTextOrEntry
... 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
... text S 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:R5-Composition-version S 0..1 string Optional Extensions Element
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
.... extension:data-enterer S 0..1 (Complex) A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension
.... extension:informant S 0..* (Complex) An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension
.... extension:information-recipient S 1..* (Complex) Information Recipient Extension
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 2..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:type 1..* Extension Extension
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "type"
....... value[x] 1..1 CodeableConcept Value of extension
Binding: Information Recipient Type (required)
...... extension:function 0..* Extension Exact function of the participant in the creation of the clinical document. This is more granular than type.
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "function"
....... value[x] 1..1 CodeableConcept Value of extension
Binding: ParticipationFunction (3.0.0) (extensible)
...... extension:time 0..1 Extension Time period of participation
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "time"
....... value[x] 1..1 Period Value of extension
...... extension:party S 1..1 Extension Extension
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..0 Extension
Slice: Unordered, Open by value:url
....... url 1..1 uri "party"
....... value[x] 1..1 Reference(AU Aged Care Clinical Note - Organization | AU Aged Care Clinical Note - Department | AU Aged Care Clinical Note - PractitionerRole) If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organisation profile.
..... url 1..1 uri "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension"
.... extension:participant S 0..* (Complex) A Participant that is not a data-enter, information-recipient nor an informant
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension
.... extension:consent S 0..* Reference(Consent) consent
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension
.... extension:basedOn S 0..* Reference(Resource) The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray.
URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
.... extension:change-made S 0..1 (Complex) Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note.
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
... Slices for modifierExtension ?! 0..* Extension Extension
Slice: Unordered, Open by value:url
.... modifierExtension:R5-Composition-status ?!S 0..1 base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status
... identifier SΣ 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 SΣ 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: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.32054
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... Slices for category SΣ 1..* CodeableConcept Categorization of Composition
Slice: Unordered, Open by value:text
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:clinicalnotecategory SΣ 1..1 CodeableConcept Category for Clinical Note
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.

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: 107903-7
...... display 1..1 string Representation defined by the system
Fixed Value: Clinical note
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system
..... text Σ 1..1 string Plain text representation of the concept
Required Pattern: Clinical Note
.... category:agedCareClinicalNoteCategory SΣ 0..1 CodeableConcept Aged Care Clinical Note
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system

Required Pattern: At least the following
...... 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: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100.32053
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text Σ 1..1 string Plain text representation of the concept
Required Pattern: Aged and Residential Care Clinical Document
... subject SΣ 1..1 Reference(AU Aged Care Clinical Note - Patient) Who and/or what the composition is about
... encounter Σ 0..1 Reference(Encounter) Context of the Composition
... date SΣ 1..1 dateTime Composition editing time
... author SΣ 1..1 Reference(AU Aged Care Clinical Note - Organization | AU Aged Care Clinical Note - PractitionerRole) If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organisation profile.
... title SΣ 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.
... Slices for attester S 0..* BackboneElement Attests to accuracy of composition
Slice: Unordered, Open by value:mode
.... attester:All Slices Content/Rules for all slices
..... 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 S 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
..... time S 0..1 dateTime When the composition was attested
..... party S 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
.... attester:legal_attester S 0..1 BackboneElement aka legal authenticator
..... 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.
Required Pattern: legal
..... time 0..1 dateTime When the composition was attested
..... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
.... attester:professional_attester S 0..* BackboneElement aka authenticator
..... 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.
Required Pattern: professional
..... time 0..1 dateTime When the composition was attested
..... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
... custodian SΣ 0..1 Reference(AU Aged Care Clinical Note - Organization) Organization which maintains the composition
... Slices for relatesTo S 0..* BackboneElement Relationships to other compositions/documents
Slice: Unordered, Open by value:code, type:target
.... relatesTo:All Slices Content/Rules for all slices
..... 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.
..... Slices for target[x] 1..1 Target of the relationship
Slice: Unordered, Open by type:$this
...... targetIdentifier Identifier
...... targetReference Reference(Composition)
...... target[x]:targetIdentifier 0..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document
.... relatesTo:replaced_document S 0..* BackboneElement The document(s) being superceded
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Required Pattern: replaces
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
...... target[x]:targetIdentifier 1..1 Identifier Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
....... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
....... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
....... value Σ 1..1 string The value that is unique
Example General: 123456
....... period Σ 0..1 Period Time period when id is/was valid for use
....... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... relatesTo:appended_document S 0..* BackboneElement The document(s) being appended too
..... 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.
Required Pattern: appends
..... Slices for target[x] 1..1 Identifier Target of the relationship
Slice: Unordered, Closed by type:$this
...... target[x]:targetIdentifier 1..1 Identifier Target of the relationship
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
....... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
....... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
....... value Σ 0..1 string The value that is unique
Example General: 123456
....... period Σ 0..1 Period Time period when id is/was valid for use
....... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... 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: ActCode (3.0.0) (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
... Slices for section SC 1..* BackboneElement Sections composing the aged care clinical note
Slice: Unordered, Open by pattern:code
Constraints: cmp-1, cmp-2
.... section:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:change-made S 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Label for section (e.g. for ToC)
..... code S 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 SC 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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
.... section:sectionNarrative SC 0..1 BackboneElement Narrative Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:change-made S 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Label for section (e.g. for ToC)
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
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: 61149-1
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... 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 SC 0..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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.
..... Slices for entry C 0..* Reference(DocumentReference) Attachments that are relevant to this section.
Slice: Unordered, Open by profile:resolve()
...... entry:attachment SC 0..* Reference(AU Aged Care Clinical Note - DocumentReference) 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
.... section:sectionMedications SC 0..1 BackboneElement Medications Section
Constraints: cmp-1, cmp-2
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
...... extension:change-made S 0..1 (Complex) Change Made
URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
...... extension:section-note 0..1 Annotation Additional notes that apply to the section (but not to a specific resource).
URL: http://hl7.org/fhir/StructureDefinition/note
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Label for section (e.g. for ToC)
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
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: 10160-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... 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 SC 1..1 Narrative Text summary of the section, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... 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.
..... Slices for entry C 0..* Reference(MedicationStatement) Medication statements that are relevant to this section.
Slice: Unordered, Open by profile:resolve()
...... entry:medicationStatement SC 0..* Reference(AU Aged Care Clinical Note - MedicationStatement) 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Composition.extension:information-recipient.​extension:type.value[x] Base required Information Recipient Type 📦0.1.0-preview This IG
Composition.extension:information-recipient.​extension:function.value[x] Base extensible ParticipationFunction 📍3.0.0 THO v7.0
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📦4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.category:clinicalnotecategory Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.category:agedCareClinicalNoteCategory Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legal_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:professional_attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
Composition.event.code Base example v3 Code System ActCode 📍3.0.0 THO v7.0
Composition.section.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:sectionNarrative.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:sectionNarrative.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionNarrative.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:sectionNarrative.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:sectionMedications.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:sectionMedications.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:sectionMedications.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:sectionMedications.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
NarrativeOrMedicationsSection error Composition Composition must have either a sectionNarrative or a sectionMedications section. section.where(code.coding.code = '61149-1').exists() or section.where(code.coding.code = '10160-0').exists()
NarrativeTextOrEntry error Composition section[sectionNarrative] must have either text or at least one entry with a DocumentReference. section.where(code.coding.code = '61149-1').all(text.exists() or entry.resolve().ofType(DocumentReference).exists())
clindoc-limit-participantType error Composition The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()
cmp-1 error Composition.section, Composition.section:sectionNarrative, Composition.section:sectionMedications 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, Composition.section:sectionNarrative, Composition.section:sectionMedications A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
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()

 

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