Clinical Document
Clinical Document
draftResource55 elementsv4.0.1
The Clinical Document profile constrains Composition to specify a clinical document (matching CDA).
The base Composition is a general resource for compositions or documents about any kind of subject that might be encountered in healthcare including such things as guidelines, medicines, etc. A clinical document is focused on documents related to the provision of care process, where the subject is a patient, a group of patients, or a closely related concept. A clinical document has additional requirements around confidentiality that do not apply in the same way to other kinds of documents.
Metadata
hl7.org/fhir- Canonical URL
- http://hl7.org/fhir/StructureDefinition/clinicaldocument
- ID
- clinicaldocument
- Type
- Base Definition
- Derivation
- constraint
- Publisher
- Health Level Seven, Inc. - Structured Documents WG
- Version
- 4.0.1
| Path | Card. | Type | Description |
|---|---|---|---|
Composition | 0..* | A set of resources composed into a single coherent clinical statement with clinical attestation | |
id | 0..1 | string | Logical id of this artifact |
meta | 0..1 | Metadata about the resource | |
implicitRules | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource contentpreferred: languages |
text | 0..1 | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources |
extension | 0..* | Extension | |
extension | 0..* | Version-specific identifier for composition | |
modifierExtension | 0..* | Extensions that cannot be ignored | |
identifier | 0..1 | Version-independent identifier for the Composition | |
status | 1..1 | code | preliminary | final | amended | entered-in-errorrequired: composition-status |
type | 1..1 | Kind of composition (LOINC if possible)preferred: doc-typecodes | |
category | 0..* | Categorization of Compositionexample: document-classcodes | |
subject | 0..1 | Who and/or what the composition is about | |
encounter | 0..1 | Context of the Composition | |
date | 1..1 | dateTime | Composition editing time |
author | 1..* | Who and/or what authored the composition | |
title | 1..1 | string | Human Readable name/title |
confidentiality | 0..1 | code | As defined by affinity domainrequired: v3-ConfidentialityClassification |
attester | 0..* | BackboneElement | Attests to accuracy of composition |
custodian | 0..1 | Organization which maintains the composition | |
relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents |
event | 0..* | BackboneElement | The clinical service(s) being documented |
section | 0..* | BackboneElement | Composition is broken into sections |