ClinicalDocument

Clinical Document

draftResource51 elementsv5.0.0

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
5.0.0
PathCard.TypeDescription
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 contentrequired: all-languages
text
0..1
Text summary of the resource, for human interpretation
contained
0..*
Resource
Contained, inline Resources
extension
0..*
Additional content defined by implementations
modifierExtension
0..*
Extensions that cannot be ignored
url
0..1
uri
Canonical identifier for this Composition, represented as a URI (globally unique)
identifier
0..*
Version-independent identifier for the Composition
version
0..1
string
An explicitly assigned identifer of a variation of the content in the Composition
status
1..1
code
registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknownrequired: composition-status
type
1..1
Kind of composition (LOINC if possible)preferred: doc-typecodes
category
0..*
Categorization of Compositionexample: referenced-item-category
subject
0..*
Who and/or what the composition is about
encounter
0..1
Context of the Composition
date
1..1
dateTime
Composition editing time
useContext
0..*
The context that the content is intended to support
author
1..*
Who and/or what authored the composition
name
0..1
string
Name for this Composition (computer friendly)
title
1..1
string
Human Readable name/title
note
0..*
For any additional notes
attester
0..*
BackboneElement
Attests to accuracy of composition
custodian
0..1
Organization which maintains the composition
relatesTo
0..*
Relationships to other compositions/documents
event
0..*
BackboneElement
The clinical service(s) being documented
section
0..*
BackboneElement
Composition is broken into sections