AU Core Implementation Guide
0.2.2-preview - Preview Australia flag

This page is part of the Australian Core IG (v0.2.2-preview: AU Core) based on FHIR R4. For a full list of available versions, see the Directory of published versions

Resource Profile: AU Core Document Composition

Official URL: http://hl7.org.au/fhir/core/StructureDefinition/au-core-documentcomposition Version: 0.2.2-preview
Standards status: Draft Maturity Level: 0 Computable Name: AUCoreCompositionDocument

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License. HL7 Australia© 2022+; Licensed Under Creative Commons No Rights Reserved.

This profile sets minimum expectations for a Composition resource to record, search, and fetch a clinical document for a patient. It is based on the AU Base Composition profile and identifies the additional mandatory core elements, extensions, vocabularies and value sets that SHALL be present in the Composition when conforming to this profile. It provides the floor for standards development for specific uses cases in an Australian context.

Usage scenarios

The following are supported usage scenarios for this profile:

  • Query for a clinical document for a patient
  • Record or update a clinical document for a patient

Comparison with other national and international specifications

A resource conforming to this profile:

  • MAY be conformant to Composition (IPS) if:
    • Composition.type is 60591-5
    • patient is supported as Composition.subject.reference
    • any section
      • does not supply Section.emptyReason or Section.section
      • supplies at least one Section.entry with a supported resource type
      • does not supply unsupported resource types in Section.entry
    • a medications section is supplied with Section.code 10160-0
    • an allergies section is supplied with Section.code 48765-2
    • a problems section is supplied with Section.code 11450-4

No equivalent International Patient Access or US Core profile.

Conformance in reverse is not guaranteed, i.e. a resource conforming to International Patient Summary MAY NOT conform to AU Core.

Profile specific implementation guidance

Composition, DocumentReference, DiagnosticReport, and List resources support support the exchange of clinical notes. Specific feedback is sought on resource selection to form agreement on the clinical notes that SHOULD be exposed via Composition.

Specific feedback is sought on the set of clinical notes and associated codes to be supported in Australia.

Specific feedback is sought on the defining the local requirements of $summary operation (IPS Summary).

Usage:

Formal Views of Profile Content

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

This structure is derived from AUBaseComposition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition C0..*AUBaseCompositionComposition for the Australian realm
au-core-doc-01: Sections shall be unique by code
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... informationRecipient S0..*Reference(Practitioner | Device | Patient | RelatedPerson | PractitionerRole | Organization)Information recipient
URL: http://hl7.org.au/fhir/StructureDefinition/information-recipient
... identifier S1..1IdentifierVersion-independent identifier for the Composition
... type S1..1CodeableConceptDocument sub type
... category S1..*CodeableConceptCategorization of Composition
... subject S1..1Reference(AU Core Patient)Who and/or what the composition is about
... encounter S0..1Reference(AU Core Encounter)Context of the Composition
... date SC1..1dateTimeComposition editing time
au-core-doc-02: Date shall be at least to day
... author S1..*Reference(AU Core PractitionerRole | AU Core System Device | AU Core Patient | AU Core RelatedPerson)Who and/or what authored the composition
... title S1..1stringHuman Readable name/title
... attester S0..*BackboneElementAttests to accuracy of composition
.... mode S1..1codepersonal | professional | legal | official
.... time S1..1dateTimeWhen the composition was attested
.... party S1..1Reference(AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson | AU Core Organization)Who attested the composition
... custodian S1..1Reference(AU Core Organization)Organization which maintains the composition
... relatesTo S0..*BackboneElementRelationships to other compositions/documents
.... code S1..1codereplaces | transforms | signs | appends
.... target[x] S1..1Identifier, Reference(Composition)Target of the relationship
... section S1..*BackboneElementComposition is broken into sections
.... title S0..1stringLabel for section (e.g. for ToC)
.... code S0..1CodeableConceptClassification of section (recommended)
.... text S0..1NarrativeText summary of the section, for human interpretation
.... mode 0..1codeworking | snapshot | changes
Fixed Value: snapshot
.... entry S0..*Reference(Resource)A reference to data that supports this section
..... reference 1..1stringLiteral reference, Relative, internal or absolute URL
.... emptyReason S0..1CodeableConceptWhy the section is empty

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
au-core-doc-01errorCompositionSections shall be unique by code
: section.select(code.coding.code).isDistinct()
au-core-doc-02errorComposition.dateDate shall be at least to day
: toString().length() >= 10

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Below is an overview of the mandatory and optional search parameters and combined search parameters. FHIR search operations and the syntax used to describe the interactions is described here.

Any search parameter defined in FHIR may be ‘allowed’ by the system unless explicitly marked as “SHALL NOT”. A few items are marked as MAY in this implementation guide to highlight their potential relevance.

Parameter(s) Conformance Type(s) Requirements (when used alone or in combination)
_id SHALL token
patient SHALL reference The client SHALL provide at least an id value and MAY provide both the Type and id values. The server SHALL support both.
patient+category SHALL reference+token
patient+category+date SHALL reference+token+date
identifier SHOULD token The client SHALL provide at least a code value and MAY provide both the system and code values. The server SHALL support both.
patient+category+status SHALL reference+token+token
patient.identifier SHOULD reference.token The client SHALL provide both the system and code values. The server SHALL support both.

The client SHOULD support search using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile. The server SHOULD support search using the using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile.
patient+status SHOULD reference+token
patient+type SHOULD reference+token
patient+type+date SHOULD reference+token+date
category MAY token The client SHALL provide at least a code value and MAY provide both the system and code values. The server SHALL support both.
type MAY token The client SHALL provide at least a code value and MAY provide both the system and code values. The server SHALL support both.
date MAY date A client SHALL provide a value precise to the second + time offset. A server SHALL support a value precise to the second + time offset.
status MAY token The client SHALL provide at least a code value and MAY provide both the system and code values. The server SHALL support both.

Mandatory Search Parameters:

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support fetching a Composition using the _id search parameter:
    • SHALL support these _revinclude parameters: Provenance:target

    GET [base]/Composition/[id] or GET [base]/Composition?_id=[id]

    Example:

    1. GET [base]/Composition/2169591
    2. GET [base]/Composition?_id=2169591

    Implementation Notes: Fetches a single Composition. The document itself is represented as a base64 encoded binary data element or retrieved using the link provided by the resource. If the document is a relative link to a [Binary] resource like a resource reference, it can be subsequently retrieved using: GET [base]/Binary/[id]. (how to search by the logical id of the resource)

  2. SHALL support searching using the patient search parameter:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])

    GET [base]/Composition?patient={Type/}[id] or optionally GET [base]/Composition?patient.identifier=[system|][code]

    Example:

    1. GET [base]/Composition?patient=5678
    2. GET [base]/Composition?patient.identifier=http://ns.electronichealth.net.au/id/medicare-number|32788511952
    3. GET [base]/Composition?patient.identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608833357361

    Implementation Notes: Fetches a bundle of all Composition resources for the specified patient (how to search by reference and how to search by token)

  3. SHALL support searching using the combination of the patient and category search parameters:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])

    GET [base]/Composition?patient={Type/}[id]&category={system|}[code]

    Example:

    1. GET [base]/Composition?patient=5678&category=http://loinc.org|18761-7

    Implementation Notes: Fetches a bundle of all Composition resources for the specified patient and a category code = 18761-7 (how to search by reference and how to search by token)

  4. SHALL support searching using the combination of the patient and category and date search parameters:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])
    • SHALL support these date comparators: gt,lt,ge,le
    • SHOULD support multipleAnd search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/Composition?patient={Type/}[id]&category={system|}[code]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]/Composition?patient=5678&category=http://loinc.org|18761-7&date=ge2020-01-01T00:00:00Z

    Implementation Notes: Fetches a bundle of all Composition resources for the specified patient and date and a category code = 18761-7 (how to search by reference and how to search by token and how to search by date)

Optional Search Parameters:

The following search parameters and search parameter combinations SHOULD be supported:

  1. SHOULD support searching using the identifier search parameter:
    • SHALL support these _revinclude parameters: Provenance:target

    GET [base]/Composition?identifier={system|}[code]

    Example:

    1. GET [base]/Composition?identifier=http://hospital.example.org|1032333

    Implementation Notes: Fetches a bundle containing any Composition resources matching the identifier (how to search by token)

  2. SHOULD support searching using the combination of the patient and category and status search parameters:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])
    • SHALL support multipleOr search on code (e.g.code={system|}[code],{system|}[code],...)
    • SHALL support multipleOr search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/Composition?patient={Type/}[id]&category={system|}[code]&status={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/Composition?patient=5678&category=http://loinc.org|18761-7&status=final

    Implementation Notes: Fetches a bundle of all Composition resources for the specified patient and category and status (how to search by reference and how to search by token)

  3. SHOULD support searching using the combination of the patient and type search parameters:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])
    • SHOULD support multipleOr search on type (e.g.type={system|}[code],{system|}[code],...)
    • SHALL support multipleOr search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/Composition?patient={Type/}[id]&type={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/Composition?patient=5678&type=http://loinc.org|60591-5,http://loinc.org|34133-9,http://loinc.org|18842-5

    Implementation Notes: Fetches a bundle of all Composition resources for the specified patient and document code(s). The Composition code parameter searches Composition.code only. (how to search by reference and how to search by token)

  4. SHOULD support searching using the combination of the patient and type and date search parameters:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code]
    • SHOULD support multipleOr search on type (e.g.type={system|}[code],{system|}[code],...)
    • SHALL support these date comparators: gt,lt,ge,le
    • SHOULD support multipleAnd search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/Composition?patient={Type/}[id]&type={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]/Composition?patient=5678&type=http://loinc.org|60591-5,http://loinc.org|34133-9,http://loinc.org|18842-5&date=ge2020-01-01T00:00:00Z
    2. GET [base]/Composition?patient.identifier=http://example.org/fhir/mrn|12345&type=type=http://loinc.org|60591-5,http://loinc.org|34133-9,http://loinc.org|18842-5&date=ge2020-01-01T00:00:00Z

    Implementation Notes: Fetches a bundle of all Composition resources for the specified patient and date and document code(s) (how to search by reference and how to search by token and how to search by date)

  5. SHOULD support searching using the combination of the patient and status search parameters:
    • SHALL support these _revinclude parameters: Provenance:target
    • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])
    • SHOULD support multipleOr search on type (e.g.type={system|}[code],{system|}[code],...)
    • SHALL support multipleOr search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/Composition?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/Composition?patient=5678&status=final

    Implementation Notes: Fetches a bundle of all Composition resources for the specified patient and status (how to search by reference and how to search by token)