AU Base Implementation Guide
4.1.0-ballot - CI Build AU

This page is part of AU Base v4.1.0 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-ballot
Draft as of 2022-11-10 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 includes core localisation concepts for use in an Australian context.

Usage Notes

When capturing a composition practitioner role as the sole author of the composition, a practitioner linked to that practitioner role is required to be supplied as a composition author. Where there is more than one author this is not necessary or recommended.

Where practicable it is preferred that the assertion of clinical judgement that there are no known items for this list is handled via an entry with the appropriate negation code over making use of section emptyReason. For example the instantiation of an AllergyIntolerance with code that is a child of 716186003 |No known allergy| from SNOMED CT[1].

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
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

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

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

This structure is derived from Composition

Summary

Extensions

This structure refers to these extensions:

Maturity: 2

 

Other representations of profile: CSV, Excel, Schematron

Notes:

none defined