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
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.
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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | Composition for the Australian realm | |
Slices for extension | 0..* | Extension | Extension 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 | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | Composition for the Australian realm | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 0..* | Extension | Extension 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..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. |
date | Σ | 1..1 | dateTime | Composition editing time |
author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
title | Σ | 1..1 | string | Human Readable name/title |
Documentation for this format |
Path | Conformance | ValueSet |
Composition.status | required | CompositionStatus |
Composition.type | preferred | FHIRDocumentTypeCodes |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | Composition | Composition for the Australian realm | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension 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..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | Σ | 0..1 | Reference(Resource) | Who and/or what the composition is about | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
date | Σ | 1..1 | dateTime | Composition editing time | ||||
author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition | ||||
title | Σ | 1..1 | string | Human Readable name/title | ||||
confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
time | 0..1 | dateTime | When the composition was attested | |||||
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
target[x] | 1..1 | Target of the relationship | ||||||
targetIdentifier | Identifier | |||||||
targetReference | Reference(Composition) | |||||||
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 0..* | CodeableConcept | Code(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 | Σ | 0..1 | Period | The period covered by the documentation | ||||
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
section | C | 0..* | BackboneElement | Composition is broken into sections | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification 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..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Composition.language | preferred | CommonLanguages
| ||||
Composition.status | required | CompositionStatus | ||||
Composition.type | preferred | FHIRDocumentTypeCodes | ||||
Composition.category | example | DocumentClassValueSet | ||||
Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
Composition.attester.mode | required | CompositionAttestationMode | ||||
Composition.relatesTo.code | required | DocumentRelationshipType | ||||
Composition.event.code | example | ActCode | ||||
Composition.section.code | example | DocumentSectionCodes | ||||
Composition.section.mode | required | ListMode | ||||
Composition.section.orderedBy | preferred | ListOrderCodes | ||||
Composition.section.emptyReason | preferred | ListEmptyReasons |
This structure is derived from Composition
Differential View
This structure is derived from Composition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | Composition for the Australian realm | |
Slices for extension | 0..* | Extension | Extension 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 | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Composition | 0..* | Composition | Composition for the Australian realm | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 0..* | Extension | Extension 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..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. |
date | Σ | 1..1 | dateTime | Composition editing time |
author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition |
title | Σ | 1..1 | string | Human Readable name/title |
Documentation for this format |
Path | Conformance | ValueSet |
Composition.status | required | CompositionStatus |
Composition.type | preferred | FHIRDocumentTypeCodes |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Composition | 0..* | Composition | Composition for the Australian realm | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension 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..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
type | Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||
category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | Σ | 0..1 | Reference(Resource) | Who and/or what the composition is about | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
date | Σ | 1..1 | dateTime | Composition editing time | ||||
author | Σ | 1..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the composition | ||||
title | Σ | 1..1 | string | Human Readable name/title | ||||
confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
attester | 0..* | BackboneElement | Attests to accuracy of composition | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
time | 0..1 | dateTime | When the composition was attested | |||||
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
target[x] | 1..1 | Target of the relationship | ||||||
targetIdentifier | Identifier | |||||||
targetReference | Reference(Composition) | |||||||
event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 0..* | CodeableConcept | Code(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 | Σ | 0..1 | Period | The period covered by the documentation | ||||
detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
section | C | 0..* | BackboneElement | Composition is broken into sections | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
title | 0..1 | string | Label for section (e.g. for ToC) | |||||
code | 0..1 | CodeableConcept | Classification 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..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
section | C | 0..* | See section (Composition) | Nested Section | ||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Composition.language | preferred | CommonLanguages
| ||||
Composition.status | required | CompositionStatus | ||||
Composition.type | preferred | FHIRDocumentTypeCodes | ||||
Composition.category | example | DocumentClassValueSet | ||||
Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
Composition.attester.mode | required | CompositionAttestationMode | ||||
Composition.relatesTo.code | required | DocumentRelationshipType | ||||
Composition.event.code | example | ActCode | ||||
Composition.section.code | example | DocumentSectionCodes | ||||
Composition.section.mode | required | ListMode | ||||
Composition.section.orderedBy | preferred | ListOrderCodes | ||||
Composition.section.emptyReason | preferred | ListEmptyReasons |
This structure is derived from Composition
Other representations of profile: CSV, Excel, Schematron
none defined