Composition

Es el encabezado del documento por tanto tiene referencias al resto de las entradas para reflejar la vinculación y anidamiento. Puede haber una firma digital (elemento signature) para todo el recurso Bundle, para autenticar el contenido del documento.

Las componentes destacables del recurso son:

Composition.subject: Sobre qué o quién versa la composición (usualmente es sobre el paciente)
Composition.author: Profesional, dispositivo, paciente o persona relacionada que crea el documento (pueden ser varios).
Composition.attester.party: Paciente o profesional que atestigua la exactitud de la composicion
Composition.custodian: Recurso Organization, que representa a la entidad que mantiene la composición
Composition.event.detail: El evento que se documenta
Composition.encounter: El encuentro clínico que brinda contexto a la composición.
Composition.section.entry: el contenido clínico del documento

Recurso Composition Implementado

- Forma Completa

Composition	S I		Composition	There are no (further) constraints on this element Element Id Composition Short description A set of resources composed into a single coherent clinical statement with clinical attestation Definition A set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained. Comments While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical. Data Type Composition Constraints dom-2:If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-1:If the resource is contained in another resource, it SHALL NOT contain any narrative `contained.text.empty()` dom-4:If 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-3:If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource `contained.where(('#'+id in %resource.descendants().reference).not()).empty()` Mappings rim:Entity. Role, or Act rim:Document[classCode="DOC" and moodCode="EVN" and isNormalAct()] cda:ClinicalDocument w5:infrastructure.documents
identifier	S Σ	0..1	Identifier	There are no (further) constraints on this element Element Id Composition.identifier Short description Logical identifier of composition (version-independent) Definition Logical identifier for the composition, assigned when created. This identifier stays constant as the composition is changed over time. Comments See discussion in resource definition for how these relate. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:Document.id / Document.setId cda:.setId w5:id
use	Σ ?!	0..0	codeBinding	There are no (further) constraints on this element Element Id Composition.identifier.use Short description usual \| official \| temp \| secondary (If known) Definition The purpose of this identifier. Requirements Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Comments This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Data Type code Binding Identifies the purpose for this identifier, if known . identifier-use (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:N/A rim:Role.code or implied by context
type	Σ	0..0	CodeableConceptBinding	There are no (further) constraints on this element Element Id Composition.identifier.type Short description Description of identifier Definition A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Requirements Allows users to make use of identifiers when the identifier system is not known. Comments This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. Data Type CodeableConcept Binding A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. identifier-type (extensible) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD v2:CX.5 rim:Role.code or implied by context
system	S Σ	1..1	uri	There are no (further) constraints on this element Element Id Composition.identifier.system Short description The namespace for the identifier value Definition Establishes the namespace for the value - that is, a URL that describes a set values that are unique. Requirements There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Comments see http://en.wikipedia.org/wiki/Uniform_resource_identifier Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Examples General http://www.acme.com/identifiers/patient Mappings rim:n/a v2:CX.4 / EI-2-4 rim:II.root or Role.id.root servd:./IdentifierType
value	S Σ	1..1	string	There are no (further) constraints on this element Element Id Composition.identifier.value Short description The value that is unique Definition The portion of the identifier typically relevant to the user and which is unique within the context of the system. Comments If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Examples General 123456 Mappings rim:n/a v2:CX.1 / EI.1 rim:II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root) servd:./Value
period	Σ I	0..0	Period	There are no (further) constraints on this element Element Id Composition.identifier.period Short description Time period when id is/was valid for use Definition Time period during which identifier is/was valid for use. Comments This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval\|Duration. Data Type Period Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` per-1:If present, start SHALL have a lower value than end `start.empty() or end.empty() or (start <= end)` Mappings rim:n/a v2:DR rim:IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"] v2:CX.7 + CX.8 rim:Role.effectiveTime or implied by context servd:./StartDate and ./EndDate
assigner	Σ I	0..0	Reference(Organization)	There are no (further) constraints on this element Element Id Composition.identifier.assigner Short description Organization that issued id (may be just text) Definition Organization that issued/manages the identifier. Comments The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. Data Type Reference(Organization) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) v2:CX.4 / (CX.4,CX.9,CX.10) rim:II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper servd:./IdentifierIssuingAuthority
status	Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element Id Composition.status Short description preliminary \| final \| amended \| entered-in-error Definition The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. Requirements Need to be able to mark interim, amended, or withdrawn compositions or documents. 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 "entered-in-error" 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. Data Type code Binding The workflow/clinical status of the composition. composition-status (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete" cda:n/a w5:status
type	Σ	1..1	CodeableConceptBinding	There are no (further) constraints on this element Element Id Composition.type Short description Kind of composition (LOINC if possible) Definition Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. Requirements Key metadata element describing the composition, used in searching/filtering. 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. Data Type CodeableConcept Binding Type of a composition. doc-typecodes (preferred) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:./code cda:.code w5:class
coding	Σ	0..*	Coding	There are no (further) constraints on this element Element Id Composition.type.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data Type Coding Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
system	Σ	0..1	uri	There are no (further) constraints on this element Element Id Composition.type.coding.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.3 rim:./codeSystem orim:*fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..0	string	There are no (further) constraints on this element Element Id Composition.type.coding.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.7 rim:./codeSystemVersion orim:*fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	0..1	code	There are no (further) constraints on this element Element Id Composition.type.coding.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings may not exceed 1MB in size Data Type code Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.1 rim:./code orim:*fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	final	Element Id Composition.type.coding.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings may not exceed 1MB in size Data Type final Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.2 - but note this is not well followed rim:CV.displayName orim:*fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..0	boolean	There are no (further) constraints on this element Element Id Composition.type.coding.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:Sometimes implied by being first rim:CD.codingRationale orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.type.text Short description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. Requirements The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Comments Very often the text is the same as a displayName of one of the codings. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.9. But note many systems use CE.2 for this rim:./originalText[mediaType/code="text/plain"]/data orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
class	Σ	0..0	CodeableConcept	There are no (further) constraints on this element Element Id Composition.class Short description Categorization of Composition Definition A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type. Requirements Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. Comments This is a metadata field from XDS/MHD. Data Type CodeableConcept Binding High-level kind of a clinical document at a macro level. doc-classcodes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code cda:n/a w5:class
subject	S Σ I	1..1	Reference(Resource)	There are no (further) constraints on this element Element Id Composition.subject Short description Who and/or what the composition is about Definition Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). Requirements Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. Comments For clinical documents, this is usually the patient. Data Type Reference(Resource) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.participation[typeCode="SBJ"].role[typeCode="PAT"] cda:.recordTarget w5:who.focus
reference	S Σ I	0..1	string	There are no (further) constraints on this element Element Id Composition.subject.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
identifier	Σ	0..0	Identifier	There are no (further) constraints on this element Element Id Composition.subject.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:.identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.subject.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
encounter	S Σ I	0..1	Reference(Encounter)	There are no (further) constraints on this element Element Id Composition.encounter Short description Context of the Composition Definition Describes the clinical encounter or type of care this documentation is associated with. Requirements Provides context for the composition and supports searching. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Encounter) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct]) cda:.componentOf.encompassingEncounter w5:context
reference	S Σ I	0..1	string	There are no (further) constraints on this element Element Id Composition.encounter.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
identifier	Σ	0..0	Identifier	There are no (further) constraints on this element Element Id Composition.encounter.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:.identifier
display	Σ	0..0	string	There are no (further) constraints on this element Element Id Composition.encounter.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
date	Σ	1..1	dateTime	There are no (further) constraints on this element Element Id Composition.date Short description Composition editing time Definition The composition editing time, when the composition was last logically changed by the author. Requirements dateTime is used for tracking, organizing versions and searching. Comments The Last Modified Date on the composition may be after the date of the document was attested without being changed. Data Type dateTime Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:.effectiveTime[type="TS"] cda:.effectiveTime w5:when.done
author	S Σ I	1..*	Reference(Practitioner \| Device \| Patient \| RelatedPerson)	There are no (further) constraints on this element Element Id Composition.author Short description Who and/or what authored the composition Definition Identifies who is responsible for the information in the composition, not necessarily who typed it in. Requirements Identifies who is responsible for the content. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Practitioner \| Device \| Patient \| RelatedPerson) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.participation[typeCode="AUT"].role[classCode="ASSIGNED"] cda:.author.assignedAuthor w5:who.author
reference	S Σ I	1..1	string	There are no (further) constraints on this element Element Id Composition.author.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
identifier	Σ	0..0	Identifier	There are no (further) constraints on this element Element Id Composition.author.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:.identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.author.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
title	Σ	1..1	string	There are no (further) constraints on this element Element Id Composition.title Short description Human Readable name/title Definition Official human-readable label for the composition. 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. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:./title cda:.title
confidentiality	Σ ?!	0..1	codeBinding	There are no (further) constraints on this element Element Id Composition.confidentiality Short description As defined by affinity domain Definition The code specifying the level of confidentiality of the Composition. 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). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. Data Type code Binding Codes specifying the level of confidentiality of the composition. HL7 v3 Value Set ConfidentialityClassification (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:.confidentialityCode cda:.confidentialityCode
attester	S Σ	1..*	BackboneElement	There are no (further) constraints on this element Element Id Composition.attester Short description Attests to accuracy of composition Definition A participant who has attested to the accuracy of the composition/document. Requirements Identifies responsibility for the accuracy of the composition content. Comments Only list each attester once. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:.participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"] cda:.authenticator/.legalAuthenticator
mode	Σ	1..1	codeBinding	There are no (further) constraints on this element Element Id Composition.attester.mode Short description personal \| professional \| legal \| official Definition The type of attestation the authenticator offers. Requirements Indicates the level of authority of the attestation. Comments Use more than one code where a single attester has more than one mode (professional and legal are often paired). Data Type code Binding The way in which a person authenticated a composition. composition-attestation-mode (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:unique(./modeCode) cda:implied by .authenticator/.legalAuthenticator
time	S Σ	1..1	dateTime	There are no (further) constraints on this element Element Id Composition.attester.time Short description When the composition was attested Definition When the composition was attested by the party. Requirements Identifies when the information in the composition was deemed accurate. (Things may have changed since then.). Data Type dateTime Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:./time[type="TS" and isNormalDatatype()] cda:.authenticator.time
party	Σ I	1..1	Reference(Patient \| Practitioner \| Organization)	There are no (further) constraints on this element Element Id Composition.attester.party Short description Who attested the composition Definition Who attested the composition in the specified way. Requirements Identifies who has taken on the responsibility for accuracy of the composition content. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Patient \| Practitioner \| Organization) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()] cda:.authenticator.assignedEnttty w5:who.witness
reference	S Σ I	1..1	string	There are no (further) constraints on this element Element Id Composition.attester.party.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
identifier	Σ	0..0	Identifier	There are no (further) constraints on this element Element Id Composition.attester.party.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:.identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.attester.party.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
custodian	S Σ I	1..1	Reference(Organization)	There are no (further) constraints on this element Element Id Composition.custodian Short description Organization which maintains the composition Definition Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. Requirements Identifies where to go to find the current version, where to report issues, etc. 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. Data Type Reference(Organization) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"] cda:.custodian.assignedCustodian
reference	S Σ I	1..1	string	There are no (further) constraints on this element Element Id Composition.custodian.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
identifier	Σ	0..1	Identifier	There are no (further) constraints on this element Element Id Composition.custodian.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:.identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.custodian.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
relatesTo	Σ	0..0	BackboneElement	There are no (further) constraints on this element Element Id Composition.relatesTo Short description Relationships to other compositions/documents Definition Relationships that this composition has with other compositions or documents that already exist. Comments A document is a version specific composition. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:.outboundRelationship cda:.relatedDocument
event	Σ	0..*	BackboneElement	There are no (further) constraints on this element Element Id Composition.event Short description The clinical service(s) being documented Definition The clinical service, such as a colonoscopy or an appendectomy, being documented. Requirements Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. Comments The event needs to be consistent with the type element, though can provide further information if desired. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT'] cda:.documentationOf.serviceEvent
code	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element Id Composition.event.code Short description Code(s) that apply to the event being documented Definition This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. 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. Data Type CodeableConcept Binding This list of codes represents the main clinical acts being documented. HL7 v3 Value Set ActCode (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:.code cda:.code
coding	Σ	0..*	Coding	There are no (further) constraints on this element Element Id Composition.event.code.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data Type Coding Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
system	Σ	0..1	uri	There are no (further) constraints on this element Element Id Composition.event.code.coding.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.3 rim:./codeSystem orim:*fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..0	string	There are no (further) constraints on this element Element Id Composition.event.code.coding.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.7 rim:./codeSystemVersion orim:*fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	0..1	code	There are no (further) constraints on this element Element Id Composition.event.code.coding.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings may not exceed 1MB in size Data Type code Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.1 rim:./code orim:*fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.event.code.coding.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings may not exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.2 - but note this is not well followed rim:CV.displayName orim:*fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..0	boolean	There are no (further) constraints on this element Element Id Composition.event.code.coding.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:Sometimes implied by being first rim:CD.codingRationale orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.event.code.text Short description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. Requirements The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Comments Very often the text is the same as a displayName of one of the codings. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.9. But note many systems use CE.2 for this rim:./originalText[mediaType/code="text/plain"]/data orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
period	Σ I	0..1	Period	There are no (further) constraints on this element Element Id Composition.event.period Short description The period covered by the documentation Definition The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. Comments This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval\|Duration. Data Type Period Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` per-1:If present, start SHALL have a lower value than end `start.empty() or end.empty() or (start <= end)` Mappings rim:n/a v2:DR rim:IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"] rim:.effectiveTime cda:.effectiveTime
detail	Σ I	0..*	Reference(Resource)	There are no (further) constraints on this element Element Id Composition.event.detail Short description The event(s) being documented Definition The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Resource) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.outboundRelationship[typeCode="SUBJ"].target cda:n/a
reference	Σ I	0..1	string	There are no (further) constraints on this element Element Id Composition.event.detail.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
identifier	Σ	0..0	Identifier	There are no (further) constraints on this element Element Id Composition.event.detail.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:.identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.event.detail.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
section	I	0..*	BackboneElement	There are no (further) constraints on this element Element Id Composition.section Short description Composition is broken into sections Definition The root of the sections that make up the composition. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` cmp-1:A section must at least one of text, entries, or sub-sections `text.exists() or entry.exists() or section.exists()` cmp-2:A section can only have an emptyReason if it is empty `emptyReason.empty() or entry.empty()` Mappings rim:n/a rim:./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] cda:.component.structuredBody.component.section
title		0..1	string	There are no (further) constraints on this element Element Id Composition.section.title Short description Label for section (e.g. for ToC) Alternate names header, label, caption Definition The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Requirements Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. 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. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:./title cda:.title
code		0..1	CodeableConcept	There are no (further) constraints on this element Element Id Composition.section.code Short description Classification of section (recommended) Definition A code identifying the kind of content contained within the section. This must be consistent with the section title. Requirements Provides computable standardized labels to topics within the document. 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. Data Type CodeableConcept Binding Classification of a section of a composition/document. doc-section-codes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:./code cda:.code
coding	Σ	0..*	Coding	There are no (further) constraints on this element Element Id Composition.section.code.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data Type Coding Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
system	Σ	0..1	uri	There are no (further) constraints on this element Element Id Composition.section.code.coding.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.3 rim:./codeSystem orim:*fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..0	string	There are no (further) constraints on this element Element Id Composition.section.code.coding.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.7 rim:./codeSystemVersion orim:*fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	0..1	code	There are no (further) constraints on this element Element Id Composition.section.code.coding.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings may not exceed 1MB in size Data Type code Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.1 rim:./code orim:*fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.section.code.coding.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings may not exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.2 - but note this is not well followed rim:CV.displayName orim:*fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..0	boolean	There are no (further) constraints on this element Element Id Composition.section.code.coding.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:Sometimes implied by being first rim:CD.codingRationale orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.section.code.text Short description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. Requirements The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Comments Very often the text is the same as a displayName of one of the codings. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.9. But note many systems use CE.2 for this rim:./originalText[mediaType/code="text/plain"]/data orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
text	I	0..1	Narrative	There are no (further) constraints on this element Element Id Composition.section.text Short description Text summary of the section, for human interpretation Definition A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Comments Document profiles may define what content should be represented in the narrative to ensure clinical safety. Data Type Narrative Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A rim:.text cda:.text
mode	Σ ?!	0..0	codeBinding	There are no (further) constraints on this element Element Id Composition.section.mode Short description working \| snapshot \| changes Definition How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Requirements Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. Comments This element is labeled as a modifier because a change list must not be mis-understood as a complete list. Data Type code Binding The processing mode that applies to this section. list-mode (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value cda:n/a w5:class
orderedBy		0..0	CodeableConceptBinding	There are no (further) constraints on this element Element Id Composition.section.orderedBy Short description Order of section entries Definition Specifies the order applied to the items in the section entries. Requirements Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. 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. Data Type CodeableConcept Binding What order applies to the items in the entry. list-order (preferred) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:.outboundRelationship[typeCode=COMP].sequenceNumber > 1 cda:n/a
entry	I	0..*	Reference(Resource)	There are no (further) constraints on this element Element Id Composition.section.entry Short description A reference to data that supports this section Definition A reference to the actual resource from which the narrative in the section is derived. Comments If there are no entries in the list, an emptyReason SHOULD be provided. Data Type Reference(Resource) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] cda:.entry
emptyReason	I	0..0	CodeableConceptBinding	There are no (further) constraints on this element Element Id Composition.section.emptyReason Short description Why the section is empty Definition If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Requirements Allows capturing things like "none exist" or "not asked" which can be important for most lists. 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. Data Type CodeableConcept Binding If a section is empty, why it is empty. list-empty-reason (preferred) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:.inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD] cda:n/a
section	I	0..0	see (section)	There are no (further) constraints on this element Element Id Composition.section.section Short description Nested Section Definition A nested sub-section within this section. Comments Nested sections are primarily used to help human readers navigate to particular portions of the document. Mappings rim:./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] cda:.component.section

- Forma Diferencial

Composition	S I		Composition	There are no (further) constraints on this element Element Id Composition Short description A set of resources composed into a single coherent clinical statement with clinical attestation Definition A set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained. Comments While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical. Data Type Composition Constraints dom-2:If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-1:If the resource is contained in another resource, it SHALL NOT contain any narrative `contained.text.empty()` dom-4:If 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-3:If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource `contained.where(('#'+id in %resource.descendants().reference).not()).empty()` Mappings rim:Entity. Role, or Act rim:Document[classCode="DOC" and moodCode="EVN" and isNormalAct()] cda:ClinicalDocument w5:infrastructure.documents
identifier	S Σ	0..1	Identifier	There are no (further) constraints on this element Element Id Composition.identifier Short description Logical identifier of composition (version-independent) Definition Logical identifier for the composition, assigned when created. This identifier stays constant as the composition is changed over time. Comments See discussion in resource definition for how these relate. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:Document.id / Document.setId cda:.setId w5:id
use	Σ ?!	0..0	codeBinding	There are no (further) constraints on this element Element Id Composition.identifier.use Short description usual \| official \| temp \| secondary (If known) Definition The purpose of this identifier. Requirements Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Comments This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Data Type code Binding Identifies the purpose for this identifier, if known . identifier-use (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:N/A rim:Role.code or implied by context
type	Σ	0..0	CodeableConceptBinding	There are no (further) constraints on this element Element Id Composition.identifier.type Short description Description of identifier Definition A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Requirements Allows users to make use of identifiers when the identifier system is not known. Comments This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. Data Type CodeableConcept Binding A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. identifier-type (extensible) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD v2:CX.5 rim:Role.code or implied by context
system	S Σ	1..1	uri	There are no (further) constraints on this element Element Id Composition.identifier.system Short description The namespace for the identifier value Definition Establishes the namespace for the value - that is, a URL that describes a set values that are unique. Requirements There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Comments see http://en.wikipedia.org/wiki/Uniform_resource_identifier Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Examples General http://www.acme.com/identifiers/patient Mappings rim:n/a v2:CX.4 / EI-2-4 rim:II.root or Role.id.root servd:./IdentifierType
value	S Σ	1..1	string	There are no (further) constraints on this element Element Id Composition.identifier.value Short description The value that is unique Definition The portion of the identifier typically relevant to the user and which is unique within the context of the system. Comments If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Examples General 123456 Mappings rim:n/a v2:CX.1 / EI.1 rim:II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root) servd:./Value
period	Σ I	0..0	Period	There are no (further) constraints on this element Element Id Composition.identifier.period Short description Time period when id is/was valid for use Definition Time period during which identifier is/was valid for use. Comments This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval\|Duration. Data Type Period Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` per-1:If present, start SHALL have a lower value than end `start.empty() or end.empty() or (start <= end)` Mappings rim:n/a v2:DR rim:IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"] v2:CX.7 + CX.8 rim:Role.effectiveTime or implied by context servd:./StartDate and ./EndDate
assigner	Σ I	0..0	Reference(Organization)	There are no (further) constraints on this element Element Id Composition.identifier.assigner Short description Organization that issued id (may be just text) Definition Organization that issued/manages the identifier. Comments The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. Data Type Reference(Organization) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) v2:CX.4 / (CX.4,CX.9,CX.10) rim:II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper servd:./IdentifierIssuingAuthority
status	Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element Id Composition.status Short description preliminary \| final \| amended \| entered-in-error Definition The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. Requirements Need to be able to mark interim, amended, or withdrawn compositions or documents. 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 "entered-in-error" 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. Data Type code Binding The workflow/clinical status of the composition. composition-status (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete" cda:n/a w5:status
type	Σ	1..1	CodeableConceptBinding	There are no (further) constraints on this element Element Id Composition.type Short description Kind of composition (LOINC if possible) Definition Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. Requirements Key metadata element describing the composition, used in searching/filtering. 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. Data Type CodeableConcept Binding Type of a composition. doc-typecodes (preferred) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:./code cda:.code w5:class
coding	Σ	0..*	Coding	There are no (further) constraints on this element Element Id Composition.type.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data Type Coding Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
system	Σ	0..1	uri	There are no (further) constraints on this element Element Id Composition.type.coding.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.3 rim:./codeSystem orim:*fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..0	string	There are no (further) constraints on this element Element Id Composition.type.coding.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.7 rim:./codeSystemVersion orim:*fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	0..1	code	There are no (further) constraints on this element Element Id Composition.type.coding.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings may not exceed 1MB in size Data Type code Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.1 rim:./code orim:*fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	final	Element Id Composition.type.coding.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings may not exceed 1MB in size Data Type final Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.2 - but note this is not well followed rim:CV.displayName orim:*fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..0	boolean	There are no (further) constraints on this element Element Id Composition.type.coding.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:Sometimes implied by being first rim:CD.codingRationale orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.type.text Short description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. Requirements The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Comments Very often the text is the same as a displayName of one of the codings. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.9. But note many systems use CE.2 for this rim:./originalText[mediaType/code="text/plain"]/data orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
class	Σ	0..0	CodeableConcept	There are no (further) constraints on this element Element Id Composition.class Short description Categorization of Composition Definition A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type. Requirements Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. Comments This is a metadata field from XDS/MHD. Data Type CodeableConcept Binding High-level kind of a clinical document at a macro level. doc-classcodes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code cda:n/a w5:class
subject	S Σ I	1..1	Reference(Resource)	There are no (further) constraints on this element Element Id Composition.subject Short description Who and/or what the composition is about Definition Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). Requirements Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. Comments For clinical documents, this is usually the patient. Data Type Reference(Resource) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.participation[typeCode="SBJ"].role[typeCode="PAT"] cda:.recordTarget w5:who.focus
reference	S Σ I	0..1	string	There are no (further) constraints on this element Element Id Composition.subject.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
identifier	Σ	0..0	Identifier	There are no (further) constraints on this element Element Id Composition.subject.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:.identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.subject.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
encounter	S Σ I	0..1	Reference(Encounter)	There are no (further) constraints on this element Element Id Composition.encounter Short description Context of the Composition Definition Describes the clinical encounter or type of care this documentation is associated with. Requirements Provides context for the composition and supports searching. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Encounter) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct]) cda:.componentOf.encompassingEncounter w5:context
reference	S Σ I	0..1	string	There are no (further) constraints on this element Element Id Composition.encounter.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
identifier	Σ	0..0	Identifier	There are no (further) constraints on this element Element Id Composition.encounter.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:.identifier
display	Σ	0..0	string	There are no (further) constraints on this element Element Id Composition.encounter.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
date	Σ	1..1	dateTime	There are no (further) constraints on this element Element Id Composition.date Short description Composition editing time Definition The composition editing time, when the composition was last logically changed by the author. Requirements dateTime is used for tracking, organizing versions and searching. Comments The Last Modified Date on the composition may be after the date of the document was attested without being changed. Data Type dateTime Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:.effectiveTime[type="TS"] cda:.effectiveTime w5:when.done
author	S Σ I	1..*	Reference(Practitioner \| Device \| Patient \| RelatedPerson)	There are no (further) constraints on this element Element Id Composition.author Short description Who and/or what authored the composition Definition Identifies who is responsible for the information in the composition, not necessarily who typed it in. Requirements Identifies who is responsible for the content. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Practitioner \| Device \| Patient \| RelatedPerson) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.participation[typeCode="AUT"].role[classCode="ASSIGNED"] cda:.author.assignedAuthor w5:who.author
reference	S Σ I	1..1	string	There are no (further) constraints on this element Element Id Composition.author.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
identifier	Σ	0..0	Identifier	There are no (further) constraints on this element Element Id Composition.author.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:.identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.author.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
title	Σ	1..1	string	There are no (further) constraints on this element Element Id Composition.title Short description Human Readable name/title Definition Official human-readable label for the composition. 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. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:./title cda:.title
confidentiality	Σ ?!	0..1	codeBinding	There are no (further) constraints on this element Element Id Composition.confidentiality Short description As defined by affinity domain Definition The code specifying the level of confidentiality of the Composition. 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). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. Data Type code Binding Codes specifying the level of confidentiality of the composition. HL7 v3 Value Set ConfidentialityClassification (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:.confidentialityCode cda:.confidentialityCode
attester	S Σ	1..*	BackboneElement	There are no (further) constraints on this element Element Id Composition.attester Short description Attests to accuracy of composition Definition A participant who has attested to the accuracy of the composition/document. Requirements Identifies responsibility for the accuracy of the composition content. Comments Only list each attester once. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:.participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"] cda:.authenticator/.legalAuthenticator
mode	Σ	1..1	codeBinding	There are no (further) constraints on this element Element Id Composition.attester.mode Short description personal \| professional \| legal \| official Definition The type of attestation the authenticator offers. Requirements Indicates the level of authority of the attestation. Comments Use more than one code where a single attester has more than one mode (professional and legal are often paired). Data Type code Binding The way in which a person authenticated a composition. composition-attestation-mode (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:unique(./modeCode) cda:implied by .authenticator/.legalAuthenticator
time	S Σ	1..1	dateTime	There are no (further) constraints on this element Element Id Composition.attester.time Short description When the composition was attested Definition When the composition was attested by the party. Requirements Identifies when the information in the composition was deemed accurate. (Things may have changed since then.). Data Type dateTime Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:./time[type="TS" and isNormalDatatype()] cda:.authenticator.time
party	Σ I	1..1	Reference(Patient \| Practitioner \| Organization)	There are no (further) constraints on this element Element Id Composition.attester.party Short description Who attested the composition Definition Who attested the composition in the specified way. Requirements Identifies who has taken on the responsibility for accuracy of the composition content. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Patient \| Practitioner \| Organization) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()] cda:.authenticator.assignedEnttty w5:who.witness
reference	S Σ I	1..1	string	There are no (further) constraints on this element Element Id Composition.attester.party.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
identifier	Σ	0..0	Identifier	There are no (further) constraints on this element Element Id Composition.attester.party.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:.identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.attester.party.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
custodian	S Σ I	1..1	Reference(Organization)	There are no (further) constraints on this element Element Id Composition.custodian Short description Organization which maintains the composition Definition Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. Requirements Identifies where to go to find the current version, where to report issues, etc. 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. Data Type Reference(Organization) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"] cda:.custodian.assignedCustodian
reference	S Σ I	1..1	string	There are no (further) constraints on this element Element Id Composition.custodian.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
identifier	Σ	0..1	Identifier	There are no (further) constraints on this element Element Id Composition.custodian.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:.identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.custodian.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
relatesTo	Σ	0..0	BackboneElement	There are no (further) constraints on this element Element Id Composition.relatesTo Short description Relationships to other compositions/documents Definition Relationships that this composition has with other compositions or documents that already exist. Comments A document is a version specific composition. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:.outboundRelationship cda:.relatedDocument
event	Σ	0..*	BackboneElement	There are no (further) constraints on this element Element Id Composition.event Short description The clinical service(s) being documented Definition The clinical service, such as a colonoscopy or an appendectomy, being documented. Requirements Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. Comments The event needs to be consistent with the type element, though can provide further information if desired. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT'] cda:.documentationOf.serviceEvent
code	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element Id Composition.event.code Short description Code(s) that apply to the event being documented Definition This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. 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. Data Type CodeableConcept Binding This list of codes represents the main clinical acts being documented. HL7 v3 Value Set ActCode (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:.code cda:.code
coding	Σ	0..*	Coding	There are no (further) constraints on this element Element Id Composition.event.code.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data Type Coding Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
system	Σ	0..1	uri	There are no (further) constraints on this element Element Id Composition.event.code.coding.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.3 rim:./codeSystem orim:*fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..0	string	There are no (further) constraints on this element Element Id Composition.event.code.coding.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.7 rim:./codeSystemVersion orim:*fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	0..1	code	There are no (further) constraints on this element Element Id Composition.event.code.coding.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings may not exceed 1MB in size Data Type code Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.1 rim:./code orim:*fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.event.code.coding.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings may not exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.2 - but note this is not well followed rim:CV.displayName orim:*fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..0	boolean	There are no (further) constraints on this element Element Id Composition.event.code.coding.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:Sometimes implied by being first rim:CD.codingRationale orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.event.code.text Short description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. Requirements The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Comments Very often the text is the same as a displayName of one of the codings. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.9. But note many systems use CE.2 for this rim:./originalText[mediaType/code="text/plain"]/data orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
period	Σ I	0..1	Period	There are no (further) constraints on this element Element Id Composition.event.period Short description The period covered by the documentation Definition The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. Comments This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval\|Duration. Data Type Period Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` per-1:If present, start SHALL have a lower value than end `start.empty() or end.empty() or (start <= end)` Mappings rim:n/a v2:DR rim:IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"] rim:.effectiveTime cda:.effectiveTime
detail	Σ I	0..*	Reference(Resource)	There are no (further) constraints on this element Element Id Composition.event.detail Short description The event(s) being documented Definition The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Resource) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.outboundRelationship[typeCode="SUBJ"].target cda:n/a
reference	Σ I	0..1	string	There are no (further) constraints on this element Element Id Composition.event.detail.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
identifier	Σ	0..0	Identifier	There are no (further) constraints on this element Element Id Composition.event.detail.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:.identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.event.detail.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A
section	I	0..*	BackboneElement	There are no (further) constraints on this element Element Id Composition.section Short description Composition is broken into sections Definition The root of the sections that make up the composition. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` cmp-1:A section must at least one of text, entries, or sub-sections `text.exists() or entry.exists() or section.exists()` cmp-2:A section can only have an emptyReason if it is empty `emptyReason.empty() or entry.empty()` Mappings rim:n/a rim:./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] cda:.component.structuredBody.component.section
title		0..1	string	There are no (further) constraints on this element Element Id Composition.section.title Short description Label for section (e.g. for ToC) Alternate names header, label, caption Definition The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Requirements Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. 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. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:./title cda:.title
code		0..1	CodeableConcept	There are no (further) constraints on this element Element Id Composition.section.code Short description Classification of section (recommended) Definition A code identifying the kind of content contained within the section. This must be consistent with the section title. Requirements Provides computable standardized labels to topics within the document. 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. Data Type CodeableConcept Binding Classification of a section of a composition/document. doc-section-codes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:./code cda:.code
coding	Σ	0..*	Coding	There are no (further) constraints on this element Element Id Composition.section.code.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data Type Coding Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
system	Σ	0..1	uri	There are no (further) constraints on this element Element Id Composition.section.code.coding.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.3 rim:./codeSystem orim:*fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..0	string	There are no (further) constraints on this element Element Id Composition.section.code.coding.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.7 rim:./codeSystemVersion orim:*fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	0..1	code	There are no (further) constraints on this element Element Id Composition.section.code.coding.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings may not exceed 1MB in size Data Type code Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.1 rim:./code orim:*fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.section.code.coding.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings may not exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.2 - but note this is not well followed rim:CV.displayName orim:*fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..0	boolean	There are no (further) constraints on this element Element Id Composition.section.code.coding.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:Sometimes implied by being first rim:CD.codingRationale orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	There are no (further) constraints on this element Element Id Composition.section.code.text Short description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. Requirements The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Comments Very often the text is the same as a displayName of one of the codings. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE.9. But note many systems use CE.2 for this rim:./originalText[mediaType/code="text/plain"]/data orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
text	I	0..1	Narrative	There are no (further) constraints on this element Element Id Composition.section.text Short description Text summary of the section, for human interpretation Definition A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Comments Document profiles may define what content should be represented in the narrative to ensure clinical safety. Data Type Narrative Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:N/A rim:.text cda:.text
mode	Σ ?!	0..0	codeBinding	There are no (further) constraints on this element Element Id Composition.section.mode Short description working \| snapshot \| changes Definition How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Requirements Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. Comments This element is labeled as a modifier because a change list must not be mis-understood as a complete list. Data Type code Binding The processing mode that applies to this section. list-mode (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a rim:.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value cda:n/a w5:class
orderedBy		0..0	CodeableConceptBinding	There are no (further) constraints on this element Element Id Composition.section.orderedBy Short description Order of section entries Definition Specifies the order applied to the items in the section entries. Requirements Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. 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. Data Type CodeableConcept Binding What order applies to the items in the entry. list-order (preferred) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:.outboundRelationship[typeCode=COMP].sequenceNumber > 1 cda:n/a
entry	I	0..*	Reference(Resource)	There are no (further) constraints on this element Element Id Composition.section.entry Short description A reference to data that supports this section Definition A reference to the actual resource from which the narrative in the section is derived. Comments If there are no entries in the list, an emptyReason SHOULD be provided. Data Type Reference(Resource) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ] cda:.entry
emptyReason	I	0..0	CodeableConceptBinding	There are no (further) constraints on this element Element Id Composition.section.emptyReason Short description Why the section is empty Definition If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Requirements Allows capturing things like "none exist" or "not asked" which can be important for most lists. 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. Data Type CodeableConcept Binding If a section is empty, why it is empty. list-empty-reason (preferred) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:.inboundRelationship[typeCode=SUBJ,code<{ListEmptyReason}].value[type=CD] cda:n/a
section	I	0..0	see (section)	There are no (further) constraints on this element Element Id Composition.section.section Short description Nested Section Definition A nested sub-section within this section. Comments Nested sections are primarily used to help human readers navigate to particular portions of the document. Mappings rim:./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct] cda:.component.section