A reference to a code defined by a terminology system.

Allows for alternative encodings within a code system, and translations to other code systems.

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.

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.

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

This is a metadata field from XDS/MHD.

High-level kind of a clinical document at a macro level.

Describes the clinical encounter or type of care this documentation is associated with.

Provides context for the composition and supports searching.

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.

The composition editing time, when the composition was last logically changed by the author.

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

Identifies who is responsible for the information in the composition, not necessarily who typed it in.

Identifies who is responsible for the content.

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.

The code specifying the level of confidentiality of the Composition.

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.

Codes specifying the level of confidentiality of the composition.

The type of attestation the authenticator offers.

Indicates the level of authority of the attestation.

Note that FHIR strings SHALL NOT exceed 1MB in size

The way in which a person authenticated a composition.

When the composition was attested by the party.

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Who attested the composition in the specified way.

Identifies who has taken on the responsibility for accuracy of the composition content.

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.

Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.

Identifies where to go to find the current version, where to report issues, etc.

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.

The type of relationship that this composition has with anther composition or document.

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

The type of relationship between documents.

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.

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.

This list of codes represents the main clinical acts being documented.

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.

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").

Period is not used for a duration (a measure of elapsed time). See Duration.

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.

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.

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.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Provides computable standardized labels to topics within the document.

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.

Classification of a section of a composition/document.

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Identifies who is responsible for the content.

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.

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

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.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

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.

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

The processing mode that applies to this section.

Specifies the order applied to the items in the section entries.

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

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.

What order applies to the items in the entry.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

If a section is empty, why it is empty.

A nested sub-section within this section.

Nested sections are primarily used to help human readers navigate to particular portions of the document.

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.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Provides computable standardized labels to topics within the document.

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.

Classification of a section of a composition/document.

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Identifies who is responsible for the content.

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.

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

The actual narrative content, a stripped down version of XHTML.

The contents of the html element are an XHTML fragment containing only the basic html formatting elements described in chapters 7-11 and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained stylesheets. The XHTML content SHALL NOT contain a head, a body, external stylesheet references, scripts, forms, base/link/xlink, frames, iframes and objects.

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.

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

The processing mode that applies to this section.

Specifies the order applied to the items in the section entries.

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

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.

What order applies to the items in the entry.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

If a section is empty, why it is empty.

A nested sub-section within this section.

Nested sections are primarily used to help human readers navigate to particular portions of the document.

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.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Provides computable standardized labels to topics within the document.

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.

Classification of a section of a composition/document.

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Identifies who is responsible for the content.

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.

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

The actual narrative content, a stripped down version of XHTML.

The contents of the html element are an XHTML fragment containing only the basic html formatting elements described in chapters 7-11 and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained stylesheets. The XHTML content SHALL NOT contain a head, a body, external stylesheet references, scripts, forms, base/link/xlink, frames, iframes and objects.

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.

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

The processing mode that applies to this section.

Specifies the order applied to the items in the section entries.

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

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.

What order applies to the items in the entry.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

If a section is empty, why it is empty.

A nested sub-section within this section.

Nested sections are primarily used to help human readers navigate to particular portions of the document.

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.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Provides computable standardized labels to topics within the document.

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.

Classification of a section of a composition/document.

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Identifies who is responsible for the content.

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.

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

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.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

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.

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

The processing mode that applies to this section.

Specifies the order applied to the items in the section entries.

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

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.

What order applies to the items in the entry.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

If a section is empty, why it is empty.

A nested sub-section within this section.

Nested sections are primarily used to help human readers navigate to particular portions of the document.

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.

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

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.

A code identifying the kind of content contained within the section. This must be consistent with the section title.

Provides computable standardized labels to topics within the document.

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.

Classification of a section of a composition/document.

Identifies who is responsible for the information in this section, not necessarily who typed it in.

Identifies who is responsible for the content.

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.

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

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.

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

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.

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

The processing mode that applies to this section.

Specifies the order applied to the items in the section entries.

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

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.

What order applies to the items in the entry.

A reference to the actual resource from which the narrative in the section is derived.

If there are no entries in the list, an emptyReason SHOULD be provided.

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

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.

If a section is empty, why it is empty.