AU Base Implementation Guide
4.1.0 - Trial Use Australia flag

This page is part of the AU Base Implementation Guide 4.1.0. It is based on FHIR R4. For a full list of available versions, see the Directory of published versions

Resource Profile: AU Base Composition

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-composition Version: 4.1.0
Standards status: Trial-use Maturity Level: 2 Computable Name: AUBaseComposition

Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved.

This profile defines a composition structure that localises core concepts for use in an Australian context. The purpose of this profile is to provide national level agreement on core localised concepts. This profile does not force conformance to core localised concepts. It enables implementers and modellers to make their own rules, i.e. profiling, about how to support these concepts for specific implementation needs.

Usage Notes

Profile specific implementation guidance:

  • It is important to clearly differentiate between representing the extent of a system’s information for a patient versus clinical judgement of no relevant finding:
    • When asserting clinical judgement that there are no items of specific interest, (e.g. no current medications, no known allergies, or no history of vaccination), Composition.section.entry with a reference to a supported FHIR resource containing the record of assertion should be sent.
      • Guidance is provided in the core FHIR specification for AllergyIntolerance and Condition, and AU Assertion of No Relevant Finding is defined in this implementation guide to support additional concepts.
    • When a statement is about the nature or extent of the information the system has access to or is permitted to share, (e.g. not asked or information withheld), Composition.section.emptyReason should be sent with an appropriate code from the ListEmptyReasons value set.

Usage:

Formal Views of Profile Content

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

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionComposition for the Australian realm
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... informationRecipient 0..*Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization)Who and/or what should receive a copy of the composition
URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type Σ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.

... date Σ1..1dateTimeComposition editing time
... author Σ1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the composition
... title Σ1..1stringHuman Readable name/title

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Composition.statusrequiredCompositionStatus
Composition.typepreferredFHIRDocumentTypeCodes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionComposition for the Australian realm
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... informationRecipient 0..*Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization)Who and/or what should receive a copy of the composition
URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierVersion-independent identifier for the Composition
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type Σ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.

... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject Σ0..1Reference(Resource)Who and/or what the composition is about
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date Σ1..1dateTimeComposition editing time
... author Σ1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the composition
... title Σ1..1stringHuman Readable name/title
... confidentiality Σ0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

... attester 0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section C0..*BackboneElementComposition is broken into sections
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification 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..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text C0..1NarrativeText summary of the section, for human interpretation
.... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

.... entry C0..*Reference(Resource)A reference to data that supports this section
.... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

.... section C0..*See section (Composition)Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
Composition.typepreferredFHIRDocumentTypeCodes
Composition.categoryexampleDocumentClassValueSet
Composition.confidentialityrequiredv3.ConfidentialityClassification
Composition.attester.moderequiredCompositionAttestationMode
Composition.relatesTo.coderequiredDocumentRelationshipType
Composition.event.codeexampleActCode
Composition.section.codeexampleDocumentSectionCodes
Composition.section.moderequiredListMode
Composition.section.orderedBypreferredListOrderCodes
Composition.section.emptyReasonpreferredListEmptyReasons

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Composition

Summary

Extensions

This structure refers to these extensions:

Maturity: 2

Differential View

This structure is derived from Composition

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionComposition for the Australian realm
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... informationRecipient 0..*Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization)Who and/or what should receive a copy of the composition
URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type Σ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.

... date Σ1..1dateTimeComposition editing time
... author Σ1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the composition
... title Σ1..1stringHuman Readable name/title

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Composition.statusrequiredCompositionStatus
Composition.typepreferredFHIRDocumentTypeCodes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCompositionIf 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-4errorCompositionIf 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-5errorCompositionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCompositionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionComposition for the Australian realm
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... informationRecipient 0..*Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization)Who and/or what should receive a copy of the composition
URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierVersion-independent identifier for the Composition
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type Σ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.

... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject Σ0..1Reference(Resource)Who and/or what the composition is about
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date Σ1..1dateTimeComposition editing time
... author Σ1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the composition
... title Σ1..1stringHuman Readable name/title
... confidentiality Σ0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

... attester 0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section C0..*BackboneElementComposition is broken into sections
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification 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..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text C0..1NarrativeText summary of the section, for human interpretation
.... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

.... entry C0..*Reference(Resource)A reference to data that supports this section
.... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

.... section C0..*See section (Composition)Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
Composition.typepreferredFHIRDocumentTypeCodes
Composition.categoryexampleDocumentClassValueSet
Composition.confidentialityrequiredv3.ConfidentialityClassification
Composition.attester.moderequiredCompositionAttestationMode
Composition.relatesTo.coderequiredDocumentRelationshipType
Composition.event.codeexampleActCode
Composition.section.codeexampleDocumentSectionCodes
Composition.section.moderequiredListMode
Composition.section.orderedBypreferredListOrderCodes
Composition.section.emptyReasonpreferredListEmptyReasons

Constraints

IdGradePath(s)DetailsRequirements
cmp-1errorComposition.sectionA section must contain at least one of text, entries, or sub-sections
: text.exists() or entry.exists() or section.exists()
cmp-2errorComposition.sectionA section can only have an emptyReason if it is empty
: emptyReason.empty() or entry.empty()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Composition

Summary

Extensions

This structure refers to these extensions:

Maturity: 2

 

Other representations of profile: CSV, Excel, Schematron