description: Base StructureDefinition for Composition Resource package_name: hl7.fhir.r2b.core derivation: specialization name: Composition type: null elements: date: isModifier: false short: Composition editing time index: 1 comments: The Last Modified Date on the composition may be after the date of the document was attested without being changed. type: dateTime mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.date} isSummary: true encounter: isModifier: false short: Context of the Composition type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.encounter} isSummary: true index: 18 section: constraint: cmp-2: {human: A section can only have an emptyReason if it is empty, severity: error, expression: emptyReason.empty() or entry.empty()} cmp-1: {human: 'A section must at least one of text, entries, or sub-sections', severity: error, expression: text.exists() or entry.exists() or section.exists()} isModifier: false short: Composition is broken into sections index: 19 type: BackboneElement mustSupport: false array: true elements: title: isModifier: false short: Label for section (e.g. for ToC) index: 20 comments: The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element. type: string mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.section.title} isSummary: false code: isModifier: false short: Classification of section (recommended) index: 21 comments: The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. type: CodeableConcept mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.section.code} isSummary: false text: isModifier: false short: Text summary of the section, for human interpretation index: 22 comments: Document profiles may define what content should be represented in the narrative to ensure clinical safety. type: Narrative mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.section.text} isSummary: false mode: isModifier: true short: working | snapshot | changes type: code mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.section.mode} isSummary: true index: 23 orderedBy: isModifier: false short: Order of section entries index: 24 comments: Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. type: CodeableConcept mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.section.orderedBy} isSummary: false entry: isModifier: false short: A reference to data that supports this section index: 25 comments: If there are no entries in the list, an emptyReason SHOULD be provided. type: Reference mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: Composition.section.entry} isSummary: false emptyReason: isModifier: false short: Why the section is empty index: 26 comments: The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. type: CodeableConcept mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.section.emptyReason} isSummary: false section: elementReference: ['http://hl7.org/fhir/StructureDefinition/Composition'] isModifier: false short: Nested Section index: 27 comments: Nested sections are primarily used to help human readers navigate to particular portions of the document. mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: Composition.section.section} isSummary: false maxLength: 0 base: {max: '*', min: 0, path: Composition.section} isSummary: false attester: isModifier: false short: Attests to accuracy of composition index: 9 comments: Only list each attester once. type: BackboneElement mustSupport: false array: true elements: mode: min: 1 isModifier: false short: personal | professional | legal | official index: 10 comments: Use more than one code where a single attester has more than one mode (professional and legal are often paired). type: code mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: Composition.attester.mode} isSummary: true time: isModifier: false short: When composition attested type: dateTime mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.attester.time} isSummary: true index: 11 party: isModifier: false short: Who attested the composition type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.attester.party} isSummary: true index: 12 maxLength: 0 base: {max: '*', min: 0, path: Composition.attester} required: [mode] isSummary: true type: isModifier: false short: Kind of composition (LOINC if possible) index: 2 comments: For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. type: CodeableConcept mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.type} isSummary: true title: isModifier: false short: Human Readable name/title index: 4 comments: For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period. type: string mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.title} isSummary: true author: min: 1 isModifier: false short: Who and/or what authored the composition index: 8 type: Reference mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: Composition.author} isSummary: true event: isModifier: false short: The clinical service(s) being documented index: 14 comments: The event needs to be consistent with the type element, though can provide further information if desired. type: BackboneElement mustSupport: false array: true elements: code: isModifier: false short: Code(s) that apply to the event being documented index: 15 comments: An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries. type: CodeableConcept mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: Composition.event.code} isSummary: true period: isModifier: false short: The period covered by the documentation type: Period mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.event.period} isSummary: true index: 16 detail: isModifier: false short: The event(s) being documented index: 17 type: Reference mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: Composition.event.detail} isSummary: true maxLength: 0 base: {max: '*', min: 0, path: Composition.event} isSummary: true custodian: isModifier: false short: Organization which maintains the composition index: 13 comments: This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However it is important that this information be known when working with a derived document, so providing a custodian is encouraged. type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.custodian} isSummary: true status: isModifier: true short: preliminary | final | amended | entered-in-error index: 5 comments: If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "withdrawn" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. type: code mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.status} isSummary: true class: isModifier: false short: Categorization of Composition index: 3 comments: This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)). type: CodeableConcept mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.class} isSummary: true identifier: isModifier: false short: Logical identifier of composition (version-independent) index: 0 comments: See discussion in resource definition for how these relate. type: Identifier mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.identifier} isSummary: true subject: isModifier: false short: Who and/or what the composition is about index: 7 comments: For clinical documents, this is usually the patient. type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.subject} isSummary: true confidentiality: isModifier: true short: As defined by affinity domain index: 6 comments: The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). type: code mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: Composition.confidentiality} isSummary: true package_version: 1.4.0 class: resource kind: resource url: http://hl7.org/fhir/StructureDefinition/Composition base: http://hl7.org/fhir/StructureDefinition/DomainResource version: null required: [author, status, subject, title, type, date]