Acute and Community Clinical Data Repository HL7® FHIR® Query Implementation Guide

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 package 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. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).

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

Constraints

dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty()
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).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-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty()
dom-6: A resource should have narrative for robust management
text.`div`.exists()

Mappings

rim: Entity. Role, or Act
workflow: Event
rim: Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
cda: ClinicalDocument
fhirdocumentreference: when described by DocumentReference

0..1

There are no (further) constraints on this element

Element id

Composition.id

Short description

Logical id of this artifact

Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Data type

There are no (further) constraints on this element

Element id

Composition.meta

Short description

Metadata about the resource

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

0..1

There are no (further) constraints on this element

Element id

Composition.meta.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.meta.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

versionId

0..1

There are no (further) constraints on this element

Element id

Composition.meta.versionId

Short description

Version specific identifier

Definition

The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.

Comments

The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

lastUpdated

S Σ

0..1

There are no (further) constraints on this element

Element id

Composition.meta.lastUpdated

Short description

When the resource version last changed

Definition

When the resource last changed - e.g. when the version changed.

Comments

This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

source

0..1

There are no (further) constraints on this element

Element id

Composition.meta.source

Short description

Identifies where the resource comes from

Definition

A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.

Comments

In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.

This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

profile

0..*

There are no (further) constraints on this element

Element id

Composition.meta.profile

Short description

Profiles this resource claims to conform to

Definition

A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

Comments

It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

security

0..*

CodingBinding

There are no (further) constraints on this element

Element id

Composition.meta.security

Short description

Security Labels applied to this resource

Definition

Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.

Comments

The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.

Data type

All Security Labels (extensible)

Binding

Security Labels from the Healthcare Privacy and Security Classification System.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

tag

0..*

There are no (further) constraints on this element

Element id

Composition.meta.tag

Short description

Tags applied to this resource

Definition

Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.

Comments

The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.

Data type

Binding

Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".

CommonTags (example)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

implicitRules

Σ ?!

0..1

There are no (further) constraints on this element

Element id

Composition.implicitRules

Short description

A set of rules under which this content was created

Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

language

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.language

Short description

Language of the resource content

Definition

The base language in which the resource is written.

Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Data type

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

text

0..1

There are no (further) constraints on this element

Element id

Composition.text

Short description

Text summary of the resource, for human interpretation

Alternate names

narrative, html, xhtml, display

Definition

A human-readable narrative that contains a summary of the resource and can be 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. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: Act.text?

contained

0..*

There are no (further) constraints on this element

Element id

Composition.contained

Short description

Contained, inline Resources

Alternate names

inline resources, anonymous resources, contained resources

Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Data type

Mappings

rim: N/A

extension

0..*

Element id

Composition.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Comments

Data type

http://ontariohealth.ca/StructureDefinition/oh-ehr-copied-participants-EXT

Slicing

Unordered, Open, by url(Value)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

copiedParticipants

S C

0..*

Extension(Reference(PractitionerEHR | PractitionerRoleEHR))

Element id

Composition.extension:copiedParticipants

Short description

Optional Extensions Element

Alternate names

extensions, user content

Definition

Extension used to CC updates to the ServiceRequest

Comments

Data type

Extension(Reference(PractitionerEHR | PractitionerRoleEHR))

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A
rim: n/a

modifierExtension

?! C

0..*

There are no (further) constraints on this element

Element id

Composition.modifierExtension

Short description

Extensions that cannot be ignored

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

identifier

S Σ

1..1

Element id

Composition.identifier

Short description

Version-independent identifier for the Composition

Definition

A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.

Comments

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.identifier
w5: FiveWs.identifier
rim: Document.id / Document.setId
cda: .setId
fhirdocumentreference: DocumentReference.masterIdentifier
CDR-data-in-v2: OBR.2

0..1

There are no (further) constraints on this element

Element id

Composition.identifier.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.identifier.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

use

Σ ?!

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.identifier.use

Short description

usual | official | temp | secondary | old (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

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Data type

Binding

Identifies the purpose for this identifier, if known .

IdentifierUse (required)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: N/A
rim: Role.code or implied by context

type

0..1

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

Identifier Type Codes (extensible)

Binding

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: CX.5
rim: Role.code or implied by context

system

S Σ

1..1

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

Identifier.system is always case sensitive.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

http://www.acme.com/identifiers/patient

Mappings

v2: CX.4 / EI-2-4
rim: II.root or Role.id.root
servd: ./IdentifierType

value

S Σ

1..1

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. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

Mappings

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

0..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: CX.7 + CX.8
rim: Role.effectiveTime or implied by context
servd: ./StartDate and ./EndDate

assigner

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

S Σ ?!

1..1

codeBinding

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

Binding

The workflow/clinical status of the composition.

CompositionStatus (required)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.status
w5: FiveWs.status
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
fhirdocumentreference: DocumentReference.status
CDR-data-in-v2: OBR.25

type

S Σ

1..1

CodeableConceptEHRBinding

Element id

Composition.type

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Key metadata element describing the composition, used in searching/filtering.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

FHIRDocumentTypeCodes (preferred)

Binding

Type of a composition.

Additional bindings

LocalDocumentType (candidate)
This value set contains all Local Codes contributed by over 160 sending systems (code systems) in HL7v2 OBR-4 and/or OBX-3 to identify the local document type/section.
ProvincialDocumentType (candidate)
This value set contains all Provincial document type Codes.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.code
w5: FiveWs.class
rim: ./code
cda: .code
fhirdocumentreference: DocumentReference.type
rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD

0..1

There are no (further) constraints on this element

Element id

Composition.type.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.type.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

coding

S Σ

1..*

There are no (further) constraints on this element

Element id

Composition.type.coding

Short description

A reference to a code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

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

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.type.coding.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

system

S Σ

1..1

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 reference to some definition that establishes the system clearly and unambiguously.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

S Σ

1..1

There are no (further) constraints on this element

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.2 - but note this is not well followed
rim: CV.displayName
orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.id

Short description

xml:id (or equivalent in JSON)

Definition

unique id for the element within a resource (for internal references)

Data type

extension

0..*

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

http://hl7.org/fhir/StructureDefinition/translation

Slicing

Unordered, Open, by url(Value)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

translation

S C

0..*

Extension(Complex)

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation

Short description

Language Translation (Localization)

Alternate names

extensions, user content

Definition

Language translation from base language of resource to another language.

Comments

Data type

Extension(Complex)

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: ST.translation

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

2..*

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

lang

1..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang

Short description

Code for Language

Definition

Code for Language.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Data type

Fixed value

lang

Mappings

rim: N/A

value[x]

1..1

Binding

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueCode

There are no (further) constraints on this element

Data type

content

1..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content

Short description

Content in other Language

Definition

Content in other Language.

Comments

The type (string or markdown) must match the context in which it is used.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

content

Mappings

rim: N/A

value[x]

1..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueString

There are no (further) constraints on this element

Data type

valueMarkdown

There are no (further) constraints on this element

Data type

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

http://hl7.org/fhir/StructureDefinition/translation

Mappings

rim: N/A

value[x]

0..0

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

value

0..1

System.String

There are no (further) constraints on this element

Element id

Composition.type.coding.display.value

Short description

Primitive value for string

Definition

The actual value

Data type

System.String

Maximum string length

1048576

userSelected

0..1

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 - e.g. 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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

S Σ

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

category

S Σ

0..*

Element id

Composition.category

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

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

Comments

This is only populated on document retrieval. It should not be used in document submission.

Data type

DocumentClassValueSet (example)

Binding

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

Additional bindings

DocumentSMD (candidate)
The document-subject-matter-domain property in LOINC characterizes the general focus or domain of knowledge represented within the content of the note.
DocumentTOS (candidate)
The document-type-of-service property in LOINC characterizes the healthcare service or activity provided to/for the patient (or other subject of the service) that is described in the document.
DocumentKOD (candidate)
The document-kind property in LOINC Characterizes the general structure of the document at a macro level.
DocumentRole (candidate)
The document-role property in LOINC characterizes the general function, responsibility, or capabilities of the author in relation to a document.
DocumentSetting (candidate)
The document-setting property in LOINC is a coarse definition of the Care Setting.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.subject
w5: FiveWs.class
rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
cda: n/a
fhirdocumentreference: DocumenttReference.category
rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD

0..1

There are no (further) constraints on this element

Element id

Composition.category.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.category.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

coding

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.category.coding

Short description

A reference to a code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

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

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.category.coding.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

system

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.category.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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.category.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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.category.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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.2 - but note this is not well followed
rim: CV.displayName
orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.id

Short description

xml:id (or equivalent in JSON)

Definition

unique id for the element within a resource (for internal references)

Data type

extension

0..*

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

http://hl7.org/fhir/StructureDefinition/translation

Slicing

Unordered, Open, by url(Value)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

translation

S C

0..*

Extension(Complex)

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation

Short description

Language Translation (Localization)

Alternate names

extensions, user content

Definition

Language translation from base language of resource to another language.

Comments

Data type

Extension(Complex)

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: ST.translation

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

2..*

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

lang

1..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang

Short description

Code for Language

Definition

Code for Language.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

lang

Mappings

rim: N/A

value[x]

1..1

Binding

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueCode

There are no (further) constraints on this element

Data type

content

1..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content

Short description

Content in other Language

Definition

Content in other Language.

Comments

The type (string or markdown) must match the context in which it is used.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

content

Mappings

rim: N/A

value[x]

1..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueString

There are no (further) constraints on this element

Data type

valueMarkdown

There are no (further) constraints on this element

Data type

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

http://hl7.org/fhir/StructureDefinition/translation

Mappings

rim: N/A

value[x]

0..0

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

value

0..1

System.String

There are no (further) constraints on this element

Element id

Composition.category.coding.display.value

Short description

Primitive value for string

Definition

The actual value

Data type

System.String

Maximum string length

1048576

userSelected

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.userSelected

Short description

If this coding was chosen directly by the user

Definition

Indicates that this coding was chosen by a user directly - e.g. 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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

S Σ

0..1

There are no (further) constraints on this element

Element id

Composition.category.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

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

subject

S Σ

1..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.subject[x]
rim: .participation[typeCode="SBJ"].role[typeCode="PAT"]
cda: .recordTarget
fhirdocumentreference: DocumentReference.subject
w5: FiveWs.subject

encounter

S Σ

0..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.context
w5: FiveWs.context
rim: unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
cda: .componentOf.encompassingEncounter
fhirdocumentreference: DocumentReference.context.encounter

0..1

There are no (further) constraints on this element

Element id

Composition.encounter.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.encounter.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

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

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.encounter.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

Comments

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

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 target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents 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.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

date

S Σ

1..1

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. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Comments

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.occurrence[x]
w5: FiveWs.done[x]
rim: .effectiveTime[type="TS"]
cda: .effectiveTime
fhirdocumentreference: DocumentReference.content.attachment.date, DocumentReference.created

author

S Σ

1..1

Reference(PractitionerRoleEHR | PractitionerEHR | OrganizationEHR)

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.

Data type

Reference(PractitionerRoleEHR | PractitionerEHR | OrganizationEHR)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.performer
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor
fhirdocumentreference: DocumentReference.agent

0..1

There are no (further) constraints on this element

Element id

Composition.author.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.author.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.author.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.author.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

Composition.author.identifier

Short description

Logical reference, when literal reference is not known

Definition

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

title

S Σ

1..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./title
cda: .title
fhirdocumentreference: DocumentReference.description, DocumentReference.content.attachment.title

confidentiality

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

v3.ConfidentialityClassification (required)

Binding

Codes specifying the level of confidentiality of the composition.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .confidentialityCode
cda: .confidentialityCode
fhirdocumentreference: DocumentReference.securityLabel

attester

0..*

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

0..1

There are no (further) constraints on this element

Element id

Composition.attester.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

mode

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.

Data type

CompositionAttestationMode (required)

Binding

The way in which a person authenticated a composition.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

0..1

Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | 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.

Data type

Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.witness
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

custodian

S Σ

1..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
cda: .custodian.assignedCustodian
fhirdocumentreference: DocumentReference.custodian

0..1

There are no (further) constraints on this element

Element id

Composition.custodian.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.custodian.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.custodian.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.custodian.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

Composition.custodian.identifier

Short description

Logical reference, when literal reference is not known

Definition

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

relatesTo

0..*

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship
cda: .relatedDocument
fhirdocumentreference: DocumentReference.relatesTo

0..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

code

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.relatesTo.code

Short description

replaces | transforms | signs | appends

Definition

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

Comments

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

Data type

DocumentRelationshipType (required)

Binding

The type of relationship between documents.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship.typeCode
cda: .relatedDocument.typeCode
fhirdocumentreference: DocumentReference.relatesTo.code

target[x]

1..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.target[x]

Short description

Target of the relationship

Definition

The target composition/document of this relationship.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .target[classCode="DOC", moodCode="EVN"].id
cda: .relatedDocument.id
fhirdocumentreference: DocumentReference.relatesTo.target

targetIdentifier

There are no (further) constraints on this element

Data type

targetReference

There are no (further) constraints on this element

Data type

event

S Σ

0..*

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
cda: .documentationOf.serviceEvent
fhirdocumentreference: DocumentReference.event
CDR-data-in-v2: PV1.10

0..1

There are no (further) constraints on this element

Element id

Composition.event.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.event.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

code

0..*

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

Binding

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

v3.ActCode (example)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .code
cda: .code
fhirdocumentreference: DocumentReference.event.code

period

S Σ

1..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .effectiveTime
cda: .effectiveTime
fhirdocumentreference: DocumentReference.event.period

0..1

There are no (further) constraints on this element

Element id

Composition.event.period.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.period.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

start

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.event.period.start

Short description

Starting time with inclusive boundary

Definition

The start of the period. The boundary is inclusive.

Comments

If the low element is missing, the meaning is that the low boundary is not known.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: per-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: DR.1
rim: ./low

end

S Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.event.period.end

Short description

End time with inclusive boundary, if not ongoing

Definition

The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.

Comments

The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.

Meaning when missing

If the end of the period is missing, it means that the period is ongoing

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: per-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: DR.2
rim: ./high

detail

S Σ

0..*

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship[typeCode="SUBJ"].target
cda: n/a

0..1

There are no (further) constraints on this element

Element id

Composition.event.detail.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.detail.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.event.detail.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.event.detail.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

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

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

section

S C

1..*

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

Constraints

cmp-1: A section must contain 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()
ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

1..1

Element id

Composition.section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Comments

This is used to maintain the order of sections in the document. SMILE will generate this id that follows the order of OBX sequence (e.g. incremental, 1,2,3)

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

title

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./title
cda: .title

code

0..1

Element id

Composition.section.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

DocumentSectionCodes (example)

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./code
cda: .code
rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.code.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

coding

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding

Short description

A reference to a code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

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

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.code.coding.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

system

S Σ

1..1

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

S Σ

1..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.2 - but note this is not well followed
rim: CV.displayName
orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.id

Short description

xml:id (or equivalent in JSON)

Definition

unique id for the element within a resource (for internal references)

Data type

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

http://hl7.org/fhir/StructureDefinition/translation

Slicing

Unordered, Open, by url(Value)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

translation

S C

0..*

Extension(Complex)

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation

Short description

Language Translation (Localization)

Alternate names

extensions, user content

Definition

Language translation from base language of resource to another language.

Comments

Data type

Extension(Complex)

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: ST.translation

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

2..*

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

lang

1..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang

Short description

Code for Language

Definition

Code for Language.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

lang

Mappings

rim: N/A

value[x]

1..1

Binding

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueCode

There are no (further) constraints on this element

Data type

content

1..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content

Short description

Content in other Language

Definition

Content in other Language.

Comments

The type (string or markdown) must match the context in which it is used.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

content

Mappings

rim: N/A

value[x]

1..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueString

There are no (further) constraints on this element

Data type

valueMarkdown

There are no (further) constraints on this element

Data type

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

http://hl7.org/fhir/StructureDefinition/translation

Mappings

rim: N/A

value[x]

0..0

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

value

0..1

System.String

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.value

Short description

Primitive value for string

Definition

The actual value

Data type

System.String

Maximum string length

1048576

userSelected

0..1

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 - e.g. 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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

S Σ

0..1

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

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

author

0..*

There are no (further) constraints on this element

Element id

Composition.section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

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).

Comments

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

0..1

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .text
cda: .text

mode

0..1

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 misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

ListMode (required)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

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

Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

S C

0..*

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

0..1

There are no (further) constraints on this element

Element id

Composition.section.entry.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.entry.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.section.entry.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.section.entry.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

Composition.section.entry.identifier

Short description

Logical reference, when literal reference is not known

Definition

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

There are no (further) constraints on this element

Element id

Composition.section.entry.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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

emptyReason

0..1

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

Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

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.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

Hybrid View

CompositionDocumentEHR (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

Comments

Data type

Constraints

dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty()
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).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-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty()
dom-6: A resource should have narrative for robust management
text.`div`.exists()

Mappings

rim: Entity. Role, or Act
workflow: Event
rim: Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
cda: ClinicalDocument
fhirdocumentreference: when described by DocumentReference

0..1

There are no (further) constraints on this element

Element id

Composition.id

Short description

Logical id of this artifact

Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Data type

There are no (further) constraints on this element

Element id

Composition.meta

Short description

Metadata about the resource

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

0..1

There are no (further) constraints on this element

Element id

Composition.meta.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.meta.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

versionId

0..1

There are no (further) constraints on this element

Element id

Composition.meta.versionId

Short description

Version specific identifier

Definition

The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.

Comments

The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

lastUpdated

S Σ

0..1

There are no (further) constraints on this element

Element id

Composition.meta.lastUpdated

Short description

When the resource version last changed

Definition

When the resource last changed - e.g. when the version changed.

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

source

0..1

There are no (further) constraints on this element

Element id

Composition.meta.source

Short description

Identifies where the resource comes from

Definition

Comments

This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

profile

0..*

There are no (further) constraints on this element

Element id

Composition.meta.profile

Short description

Profiles this resource claims to conform to

Definition

A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

Comments

It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

security

0..*

CodingBinding

There are no (further) constraints on this element

Element id

Composition.meta.security

Short description

Security Labels applied to this resource

Definition

Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.

Comments

The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.

Data type

All Security Labels (extensible)

Binding

Security Labels from the Healthcare Privacy and Security Classification System.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

tag

0..*

There are no (further) constraints on this element

Element id

Composition.meta.tag

Short description

Tags applied to this resource

Definition

Comments

The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.

Data type

Binding

Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".

CommonTags (example)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

implicitRules

Σ ?!

0..1

There are no (further) constraints on this element

Element id

Composition.implicitRules

Short description

A set of rules under which this content was created

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

language

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.language

Short description

Language of the resource content

Definition

The base language in which the resource is written.

Comments

Data type

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

text

0..1

There are no (further) constraints on this element

Element id

Composition.text

Short description

Text summary of the resource, for human interpretation

Alternate names

narrative, html, xhtml, display

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: Act.text?

contained

0..*

There are no (further) constraints on this element

Element id

Composition.contained

Short description

Contained, inline Resources

Alternate names

inline resources, anonymous resources, contained resources

Definition

Comments

Data type

Mappings

rim: N/A

extension

0..*

Element id

Composition.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

http://ontariohealth.ca/StructureDefinition/oh-ehr-copied-participants-EXT

Slicing

Unordered, Open, by url(Value)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

copiedParticipants

S C

0..*

Extension(Reference(PractitionerEHR | PractitionerRoleEHR))

Element id

Composition.extension:copiedParticipants

Short description

Optional Extensions Element

Alternate names

extensions, user content

Definition

Extension used to CC updates to the ServiceRequest

Comments

Data type

Extension(Reference(PractitionerEHR | PractitionerRoleEHR))

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A
rim: n/a

modifierExtension

?! C

0..*

There are no (further) constraints on this element

Element id

Composition.modifierExtension

Short description

Extensions that cannot be ignored

Alternate names

extensions, user content

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

identifier

S Σ

1..1

Element id

Composition.identifier

Short description

Version-independent identifier for the Composition

Definition

A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.

Comments

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.identifier
w5: FiveWs.identifier
rim: Document.id / Document.setId
cda: .setId
fhirdocumentreference: DocumentReference.masterIdentifier
CDR-data-in-v2: OBR.2

0..1

There are no (further) constraints on this element

Element id

Composition.identifier.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.identifier.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

use

Σ ?!

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.identifier.use

Short description

usual | official | temp | secondary | old (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

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Data type

Binding

Identifies the purpose for this identifier, if known .

IdentifierUse (required)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: N/A
rim: Role.code or implied by context

type

0..1

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

Data type

Identifier Type Codes (extensible)

Binding

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: CX.5
rim: Role.code or implied by context

system

S Σ

1..1

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

Identifier.system is always case sensitive.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

http://www.acme.com/identifiers/patient

Mappings

v2: CX.4 / EI-2-4
rim: II.root or Role.id.root
servd: ./IdentifierType

value

S Σ

1..1

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

Mappings

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

0..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: CX.7 + CX.8
rim: Role.effectiveTime or implied by context
servd: ./StartDate and ./EndDate

assigner

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

S Σ ?!

1..1

codeBinding

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

Data type

Binding

The workflow/clinical status of the composition.

CompositionStatus (required)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.status
w5: FiveWs.status
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
fhirdocumentreference: DocumentReference.status
CDR-data-in-v2: OBR.25

type

S Σ

1..1

CodeableConceptEHRBinding

Element id

Composition.type

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Key metadata element describing the composition, used in searching/filtering.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

FHIRDocumentTypeCodes (preferred)

Binding

Type of a composition.

Additional bindings

LocalDocumentType (candidate)
This value set contains all Local Codes contributed by over 160 sending systems (code systems) in HL7v2 OBR-4 and/or OBX-3 to identify the local document type/section.
ProvincialDocumentType (candidate)
This value set contains all Provincial document type Codes.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.code
w5: FiveWs.class
rim: ./code
cda: .code
fhirdocumentreference: DocumentReference.type
rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD

0..1

There are no (further) constraints on this element

Element id

Composition.type.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.type.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

coding

S Σ

1..*

There are no (further) constraints on this element

Element id

Composition.type.coding

Short description

A reference to a code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

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

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.type.coding.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

system

S Σ

1..1

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

S Σ

1..1

There are no (further) constraints on this element

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.2 - but note this is not well followed
rim: CV.displayName
orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.id

Short description

xml:id (or equivalent in JSON)

Definition

unique id for the element within a resource (for internal references)

Data type

extension

0..*

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

http://hl7.org/fhir/StructureDefinition/translation

Slicing

Unordered, Open, by url(Value)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

translation

S C

0..*

Extension(Complex)

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation

Short description

Language Translation (Localization)

Alternate names

extensions, user content

Definition

Language translation from base language of resource to another language.

Comments

Data type

Extension(Complex)

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: ST.translation

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

2..*

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

lang

1..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang

Short description

Code for Language

Definition

Code for Language.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

lang

Mappings

rim: N/A

value[x]

1..1

Binding

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueCode

There are no (further) constraints on this element

Data type

content

1..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content

Short description

Content in other Language

Definition

Content in other Language.

Comments

The type (string or markdown) must match the context in which it is used.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

content

Mappings

rim: N/A

value[x]

1..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueString

There are no (further) constraints on this element

Data type

valueMarkdown

There are no (further) constraints on this element

Data type

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

http://hl7.org/fhir/StructureDefinition/translation

Mappings

rim: N/A

value[x]

0..0

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

value

0..1

System.String

There are no (further) constraints on this element

Element id

Composition.type.coding.display.value

Short description

Primitive value for string

Definition

The actual value

Data type

System.String

Maximum string length

1048576

userSelected

0..1

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 - e.g. 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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

S Σ

0..1

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

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

category

S Σ

0..*

Element id

Composition.category

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

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

Comments

This is only populated on document retrieval. It should not be used in document submission.

Data type

DocumentClassValueSet (example)

Binding

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

Additional bindings

DocumentSMD (candidate)
The document-subject-matter-domain property in LOINC characterizes the general focus or domain of knowledge represented within the content of the note.
DocumentTOS (candidate)
The document-type-of-service property in LOINC characterizes the healthcare service or activity provided to/for the patient (or other subject of the service) that is described in the document.
DocumentKOD (candidate)
The document-kind property in LOINC Characterizes the general structure of the document at a macro level.
DocumentRole (candidate)
The document-role property in LOINC characterizes the general function, responsibility, or capabilities of the author in relation to a document.
DocumentSetting (candidate)
The document-setting property in LOINC is a coarse definition of the Care Setting.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.subject
w5: FiveWs.class
rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
cda: n/a
fhirdocumentreference: DocumenttReference.category
rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD

0..1

There are no (further) constraints on this element

Element id

Composition.category.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.category.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

coding

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.category.coding

Short description

A reference to a code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

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

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.category.coding.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

system

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.category.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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.category.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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.category.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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.2 - but note this is not well followed
rim: CV.displayName
orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.id

Short description

xml:id (or equivalent in JSON)

Definition

unique id for the element within a resource (for internal references)

Data type

extension

0..*

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

http://hl7.org/fhir/StructureDefinition/translation

Slicing

Unordered, Open, by url(Value)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

translation

S C

0..*

Extension(Complex)

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation

Short description

Language Translation (Localization)

Alternate names

extensions, user content

Definition

Language translation from base language of resource to another language.

Comments

Data type

Extension(Complex)

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: ST.translation

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

2..*

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

lang

1..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang

Short description

Code for Language

Definition

Code for Language.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

lang

Mappings

rim: N/A

value[x]

1..1

Binding

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueCode

There are no (further) constraints on this element

Data type

content

1..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content

Short description

Content in other Language

Definition

Content in other Language.

Comments

The type (string or markdown) must match the context in which it is used.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

content

Mappings

rim: N/A

value[x]

1..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueString

There are no (further) constraints on this element

Data type

valueMarkdown

There are no (further) constraints on this element

Data type

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

http://hl7.org/fhir/StructureDefinition/translation

Mappings

rim: N/A

value[x]

0..0

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

value

0..1

System.String

There are no (further) constraints on this element

Element id

Composition.category.coding.display.value

Short description

Primitive value for string

Definition

The actual value

Data type

System.String

Maximum string length

1048576

userSelected

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.userSelected

Short description

If this coding was chosen directly by the user

Definition

Indicates that this coding was chosen by a user directly - e.g. 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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

S Σ

0..1

There are no (further) constraints on this element

Element id

Composition.category.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

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

subject

S Σ

1..1

Element id

Composition.subject

Short description

Who and/or what the composition is about

Definition

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.subject[x]
rim: .participation[typeCode="SBJ"].role[typeCode="PAT"]
cda: .recordTarget
fhirdocumentreference: DocumentReference.subject
w5: FiveWs.subject

encounter

S Σ

0..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.context
w5: FiveWs.context
rim: unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
cda: .componentOf.encompassingEncounter
fhirdocumentreference: DocumentReference.context.encounter

0..1

There are no (further) constraints on this element

Element id

Composition.encounter.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.encounter.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.encounter.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.encounter.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

Composition.encounter.identifier

Short description

Logical reference, when literal reference is not known

Definition

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

date

S Σ

1..1

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. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Comments

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.occurrence[x]
w5: FiveWs.done[x]
rim: .effectiveTime[type="TS"]
cda: .effectiveTime
fhirdocumentreference: DocumentReference.content.attachment.date, DocumentReference.created

author

S Σ

1..1

Reference(PractitionerRoleEHR | PractitionerEHR | OrganizationEHR)

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.

Data type

Reference(PractitionerRoleEHR | PractitionerEHR | OrganizationEHR)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.performer
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor
fhirdocumentreference: DocumentReference.agent

0..1

There are no (further) constraints on this element

Element id

Composition.author.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.author.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.author.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.author.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

Composition.author.identifier

Short description

Logical reference, when literal reference is not known

Definition

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

title

S Σ

1..1

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./title
cda: .title
fhirdocumentreference: DocumentReference.description, DocumentReference.content.attachment.title

confidentiality

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

Data type

v3.ConfidentialityClassification (required)

Binding

Codes specifying the level of confidentiality of the composition.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .confidentialityCode
cda: .confidentialityCode
fhirdocumentreference: DocumentReference.securityLabel

attester

0..*

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

0..1

There are no (further) constraints on this element

Element id

Composition.attester.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

mode

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.

Data type

CompositionAttestationMode (required)

Binding

The way in which a person authenticated a composition.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

0..1

Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | 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.

Data type

Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.witness
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

custodian

S Σ

1..1

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
cda: .custodian.assignedCustodian
fhirdocumentreference: DocumentReference.custodian

0..1

There are no (further) constraints on this element

Element id

Composition.custodian.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.custodian.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.custodian.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.custodian.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

Composition.custodian.identifier

Short description

Logical reference, when literal reference is not known

Definition

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

relatesTo

0..*

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship
cda: .relatedDocument
fhirdocumentreference: DocumentReference.relatesTo

0..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

code

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.relatesTo.code

Short description

replaces | transforms | signs | appends

Definition

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

Comments

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

Data type

DocumentRelationshipType (required)

Binding

The type of relationship between documents.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship.typeCode
cda: .relatedDocument.typeCode
fhirdocumentreference: DocumentReference.relatesTo.code

target[x]

1..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.target[x]

Short description

Target of the relationship

Definition

The target composition/document of this relationship.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .target[classCode="DOC", moodCode="EVN"].id
cda: .relatedDocument.id
fhirdocumentreference: DocumentReference.relatesTo.target

targetIdentifier

There are no (further) constraints on this element

Data type

targetReference

There are no (further) constraints on this element

Data type

event

S Σ

0..*

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
cda: .documentationOf.serviceEvent
fhirdocumentreference: DocumentReference.event
CDR-data-in-v2: PV1.10

0..1

There are no (further) constraints on this element

Element id

Composition.event.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.event.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

code

0..*

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

Comments

Data type

Binding

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

v3.ActCode (example)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .code
cda: .code
fhirdocumentreference: DocumentReference.event.code

period

S Σ

1..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .effectiveTime
cda: .effectiveTime
fhirdocumentreference: DocumentReference.event.period

0..1

There are no (further) constraints on this element

Element id

Composition.event.period.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.period.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

start

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.event.period.start

Short description

Starting time with inclusive boundary

Definition

The start of the period. The boundary is inclusive.

Comments

If the low element is missing, the meaning is that the low boundary is not known.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: per-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: DR.1
rim: ./low

end

S Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.event.period.end

Short description

End time with inclusive boundary, if not ongoing

Definition

Comments

The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.

Meaning when missing

If the end of the period is missing, it means that the period is ongoing

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: per-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: DR.2
rim: ./high

detail

S Σ

0..*

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship[typeCode="SUBJ"].target
cda: n/a

0..1

There are no (further) constraints on this element

Element id

Composition.event.detail.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.detail.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.event.detail.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.event.detail.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

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

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

section

S C

1..*

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

Constraints

cmp-1: A section must contain 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()
ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

1..1

Element id

Composition.section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Comments

This is used to maintain the order of sections in the document. SMILE will generate this id that follows the order of OBX sequence (e.g. incremental, 1,2,3)

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

title

0..1

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./title
cda: .title

code

0..1

Element id

Composition.section.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

DocumentSectionCodes (example)

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./code
cda: .code
rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.code.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

coding

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding

Short description

A reference to a code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

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

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.code.coding.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

system

S Σ

1..1

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

S Σ

1..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.2 - but note this is not well followed
rim: CV.displayName
orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.id

Short description

xml:id (or equivalent in JSON)

Definition

unique id for the element within a resource (for internal references)

Data type

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

http://hl7.org/fhir/StructureDefinition/translation

Slicing

Unordered, Open, by url(Value)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

translation

S C

0..*

Extension(Complex)

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation

Short description

Language Translation (Localization)

Alternate names

extensions, user content

Definition

Language translation from base language of resource to another language.

Comments

Data type

Extension(Complex)

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: ST.translation

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

2..*

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

lang

1..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang

Short description

Code for Language

Definition

Code for Language.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

lang

Mappings

rim: N/A

value[x]

1..1

Binding

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueCode

There are no (further) constraints on this element

Data type

content

1..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content

Short description

Content in other Language

Definition

Content in other Language.

Comments

The type (string or markdown) must match the context in which it is used.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

content

Mappings

rim: N/A

value[x]

1..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueString

There are no (further) constraints on this element

Data type

valueMarkdown

There are no (further) constraints on this element

Data type

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

http://hl7.org/fhir/StructureDefinition/translation

Mappings

rim: N/A

value[x]

0..0

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

value

0..1

System.String

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.value

Short description

Primitive value for string

Definition

The actual value

Data type

System.String

Maximum string length

1048576

userSelected

0..1

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 - e.g. 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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

S Σ

0..1

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

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

author

0..*

There are no (further) constraints on this element

Element id

Composition.section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

0..1

There are no (further) constraints on this element

Element id

Composition.section.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section.mode

Short description

working | snapshot | changes

Definition

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 misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

ListMode (required)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

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

Data type

Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

S C

0..*

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

0..1

There are no (further) constraints on this element

Element id

Composition.section.entry.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.entry.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.section.entry.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.section.entry.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

Composition.section.entry.identifier

Short description

Logical reference, when literal reference is not known

Definition

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

There are no (further) constraints on this element

Element id

Composition.section.entry.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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

emptyReason

0..1

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

Data type

Binding

If a section is empty, why it is empty.

ListEmptyReasons (preferred)

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
cda: n/a

section

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.

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.section

Snapshot View

CompositionDocumentEHR (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

Comments

Data type

Constraints

dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty()
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).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-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty()
dom-6: A resource should have narrative for robust management
text.`div`.exists()

Mappings

rim: Entity. Role, or Act
workflow: Event
rim: Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
cda: ClinicalDocument
fhirdocumentreference: when described by DocumentReference

0..1

There are no (further) constraints on this element

Element id

Composition.id

Short description

Logical id of this artifact

Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Data type

There are no (further) constraints on this element

Element id

Composition.meta

Short description

Metadata about the resource

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

0..1

There are no (further) constraints on this element

Element id

Composition.meta.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.meta.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

versionId

0..1

There are no (further) constraints on this element

Element id

Composition.meta.versionId

Short description

Version specific identifier

Definition

The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.

Comments

The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

lastUpdated

S Σ

0..1

There are no (further) constraints on this element

Element id

Composition.meta.lastUpdated

Short description

When the resource version last changed

Definition

When the resource last changed - e.g. when the version changed.

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

source

0..1

There are no (further) constraints on this element

Element id

Composition.meta.source

Short description

Identifies where the resource comes from

Definition

Comments

This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

profile

0..*

There are no (further) constraints on this element

Element id

Composition.meta.profile

Short description

Profiles this resource claims to conform to

Definition

A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

Comments

It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

security

0..*

CodingBinding

There are no (further) constraints on this element

Element id

Composition.meta.security

Short description

Security Labels applied to this resource

Definition

Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.

Comments

The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.

Data type

All Security Labels (extensible)

Binding

Security Labels from the Healthcare Privacy and Security Classification System.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

tag

0..*

There are no (further) constraints on this element

Element id

Composition.meta.tag

Short description

Tags applied to this resource

Definition

Comments

The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.

Data type

Binding

Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".

CommonTags (example)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

implicitRules

Σ ?!

0..1

There are no (further) constraints on this element

Element id

Composition.implicitRules

Short description

A set of rules under which this content was created

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

language

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.language

Short description

Language of the resource content

Definition

The base language in which the resource is written.

Comments

Data type

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

text

0..1

There are no (further) constraints on this element

Element id

Composition.text

Short description

Text summary of the resource, for human interpretation

Alternate names

narrative, html, xhtml, display

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: Act.text?

contained

0..*

There are no (further) constraints on this element

Element id

Composition.contained

Short description

Contained, inline Resources

Alternate names

inline resources, anonymous resources, contained resources

Definition

Comments

Data type

Mappings

rim: N/A

extension

0..*

Element id

Composition.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

http://ontariohealth.ca/StructureDefinition/oh-ehr-copied-participants-EXT

Slicing

Unordered, Open, by url(Value)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

copiedParticipants

S C

0..*

Extension(Reference(PractitionerEHR | PractitionerRoleEHR))

Element id

Composition.extension:copiedParticipants

Short description

Optional Extensions Element

Alternate names

extensions, user content

Definition

Extension used to CC updates to the ServiceRequest

Comments

Data type

Extension(Reference(PractitionerEHR | PractitionerRoleEHR))

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A
rim: n/a

modifierExtension

?! C

0..*

There are no (further) constraints on this element

Element id

Composition.modifierExtension

Short description

Extensions that cannot be ignored

Alternate names

extensions, user content

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

identifier

S Σ

1..1

Element id

Composition.identifier

Short description

Version-independent identifier for the Composition

Definition

A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.

Comments

Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.identifier
w5: FiveWs.identifier
rim: Document.id / Document.setId
cda: .setId
fhirdocumentreference: DocumentReference.masterIdentifier
CDR-data-in-v2: OBR.2

0..1

There are no (further) constraints on this element

Element id

Composition.identifier.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.identifier.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

use

Σ ?!

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.identifier.use

Short description

usual | official | temp | secondary | old (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

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Data type

Binding

Identifies the purpose for this identifier, if known .

IdentifierUse (required)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: N/A
rim: Role.code or implied by context

type

0..1

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

Data type

Identifier Type Codes (extensible)

Binding

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: CX.5
rim: Role.code or implied by context

system

S Σ

1..1

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

Identifier.system is always case sensitive.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

http://www.acme.com/identifiers/patient

Mappings

v2: CX.4 / EI-2-4
rim: II.root or Role.id.root
servd: ./IdentifierType

value

S Σ

1..1

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

Mappings

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

0..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: CX.7 + CX.8
rim: Role.effectiveTime or implied by context
servd: ./StartDate and ./EndDate

assigner

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

S Σ ?!

1..1

codeBinding

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

Data type

Binding

The workflow/clinical status of the composition.

CompositionStatus (required)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.status
w5: FiveWs.status
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
fhirdocumentreference: DocumentReference.status
CDR-data-in-v2: OBR.25

type

S Σ

1..1

CodeableConceptEHRBinding

Element id

Composition.type

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Key metadata element describing the composition, used in searching/filtering.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

FHIRDocumentTypeCodes (preferred)

Binding

Type of a composition.

Additional bindings

LocalDocumentType (candidate)
This value set contains all Local Codes contributed by over 160 sending systems (code systems) in HL7v2 OBR-4 and/or OBX-3 to identify the local document type/section.
ProvincialDocumentType (candidate)
This value set contains all Provincial document type Codes.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.code
w5: FiveWs.class
rim: ./code
cda: .code
fhirdocumentreference: DocumentReference.type
rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD

0..1

There are no (further) constraints on this element

Element id

Composition.type.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.type.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

coding

S Σ

1..*

There are no (further) constraints on this element

Element id

Composition.type.coding

Short description

A reference to a code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

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

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.type.coding.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

system

S Σ

1..1

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

S Σ

1..1

There are no (further) constraints on this element

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.2 - but note this is not well followed
rim: CV.displayName
orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.id

Short description

xml:id (or equivalent in JSON)

Definition

unique id for the element within a resource (for internal references)

Data type

extension

0..*

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

http://hl7.org/fhir/StructureDefinition/translation

Slicing

Unordered, Open, by url(Value)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

translation

S C

0..*

Extension(Complex)

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation

Short description

Language Translation (Localization)

Alternate names

extensions, user content

Definition

Language translation from base language of resource to another language.

Comments

Data type

Extension(Complex)

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: ST.translation

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

2..*

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

lang

1..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang

Short description

Code for Language

Definition

Code for Language.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

lang

Mappings

rim: N/A

value[x]

1..1

Binding

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:lang.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueCode

There are no (further) constraints on this element

Data type

content

1..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content

Short description

Content in other Language

Definition

Content in other Language.

Comments

The type (string or markdown) must match the context in which it is used.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

content

Mappings

rim: N/A

value[x]

1..1

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.extension:content.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueString

There are no (further) constraints on this element

Data type

valueMarkdown

There are no (further) constraints on this element

Data type

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

http://hl7.org/fhir/StructureDefinition/translation

Mappings

rim: N/A

value[x]

0..0

There are no (further) constraints on this element

Element id

Composition.type.coding.display.extension:translation.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

value

0..1

System.String

There are no (further) constraints on this element

Element id

Composition.type.coding.display.value

Short description

Primitive value for string

Definition

The actual value

Data type

System.String

Maximum string length

1048576

userSelected

0..1

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 - e.g. 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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

S Σ

0..1

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

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

category

S Σ

0..*

Element id

Composition.category

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

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

Comments

This is only populated on document retrieval. It should not be used in document submission.

Data type

DocumentClassValueSet (example)

Binding

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

Additional bindings

DocumentSMD (candidate)
The document-subject-matter-domain property in LOINC characterizes the general focus or domain of knowledge represented within the content of the note.
DocumentTOS (candidate)
The document-type-of-service property in LOINC characterizes the healthcare service or activity provided to/for the patient (or other subject of the service) that is described in the document.
DocumentKOD (candidate)
The document-kind property in LOINC Characterizes the general structure of the document at a macro level.
DocumentRole (candidate)
The document-role property in LOINC characterizes the general function, responsibility, or capabilities of the author in relation to a document.
DocumentSetting (candidate)
The document-setting property in LOINC is a coarse definition of the Care Setting.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.subject
w5: FiveWs.class
rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
cda: n/a
fhirdocumentreference: DocumenttReference.category
rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD

0..1

There are no (further) constraints on this element

Element id

Composition.category.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.category.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

coding

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.category.coding

Short description

A reference to a code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

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

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.category.coding.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

system

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.category.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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.category.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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.category.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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.2 - but note this is not well followed
rim: CV.displayName
orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.id

Short description

xml:id (or equivalent in JSON)

Definition

unique id for the element within a resource (for internal references)

Data type

extension

0..*

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

http://hl7.org/fhir/StructureDefinition/translation

Slicing

Unordered, Open, by url(Value)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

translation

S C

0..*

Extension(Complex)

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation

Short description

Language Translation (Localization)

Alternate names

extensions, user content

Definition

Language translation from base language of resource to another language.

Comments

Data type

Extension(Complex)

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: ST.translation

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

2..*

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

lang

1..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang

Short description

Code for Language

Definition

Code for Language.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

lang

Mappings

rim: N/A

value[x]

1..1

Binding

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:lang.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueCode

There are no (further) constraints on this element

Data type

content

1..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content

Short description

Content in other Language

Definition

Content in other Language.

Comments

The type (string or markdown) must match the context in which it is used.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

content

Mappings

rim: N/A

value[x]

1..1

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.extension:content.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueString

There are no (further) constraints on this element

Data type

valueMarkdown

There are no (further) constraints on this element

Data type

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

http://hl7.org/fhir/StructureDefinition/translation

Mappings

rim: N/A

value[x]

0..0

There are no (further) constraints on this element

Element id

Composition.category.coding.display.extension:translation.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

value

0..1

System.String

There are no (further) constraints on this element

Element id

Composition.category.coding.display.value

Short description

Primitive value for string

Definition

The actual value

Data type

System.String

Maximum string length

1048576

userSelected

0..1

There are no (further) constraints on this element

Element id

Composition.category.coding.userSelected

Short description

If this coding was chosen directly by the user

Definition

Indicates that this coding was chosen by a user directly - e.g. 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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

S Σ

0..1

There are no (further) constraints on this element

Element id

Composition.category.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

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

subject

S Σ

1..1

Element id

Composition.subject

Short description

Who and/or what the composition is about

Definition

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.subject[x]
rim: .participation[typeCode="SBJ"].role[typeCode="PAT"]
cda: .recordTarget
fhirdocumentreference: DocumentReference.subject
w5: FiveWs.subject

encounter

S Σ

0..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.context
w5: FiveWs.context
rim: unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
cda: .componentOf.encompassingEncounter
fhirdocumentreference: DocumentReference.context.encounter

0..1

There are no (further) constraints on this element

Element id

Composition.encounter.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.encounter.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.encounter.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.encounter.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

Composition.encounter.identifier

Short description

Logical reference, when literal reference is not known

Definition

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

date

S Σ

1..1

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. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Comments

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.occurrence[x]
w5: FiveWs.done[x]
rim: .effectiveTime[type="TS"]
cda: .effectiveTime
fhirdocumentreference: DocumentReference.content.attachment.date, DocumentReference.created

author

S Σ

1..1

Reference(PractitionerRoleEHR | PractitionerEHR | OrganizationEHR)

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.

Data type

Reference(PractitionerRoleEHR | PractitionerEHR | OrganizationEHR)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.performer
w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor
fhirdocumentreference: DocumentReference.agent

0..1

There are no (further) constraints on this element

Element id

Composition.author.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.author.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.author.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.author.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

Composition.author.identifier

Short description

Logical reference, when literal reference is not known

Definition

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

title

S Σ

1..1

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./title
cda: .title
fhirdocumentreference: DocumentReference.description, DocumentReference.content.attachment.title

confidentiality

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

Data type

v3.ConfidentialityClassification (required)

Binding

Codes specifying the level of confidentiality of the composition.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .confidentialityCode
cda: .confidentialityCode
fhirdocumentreference: DocumentReference.securityLabel

attester

0..*

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
cda: .authenticator/.legalAuthenticator
fhirdocumentreference: DocumentReference.authenticator

0..1

There are no (further) constraints on this element

Element id

Composition.attester.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.attester.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.attester.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

mode

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.

Data type

CompositionAttestationMode (required)

Binding

The way in which a person authenticated a composition.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: unique(./modeCode)
cda: implied by .authenticator/.legalAuthenticator

time

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./time[type="TS" and isNormalDatatype()]
cda: .authenticator.time

party

0..1

Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | 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.

Data type

Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.witness
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

custodian

S Σ

1..1

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
cda: .custodian.assignedCustodian
fhirdocumentreference: DocumentReference.custodian

0..1

There are no (further) constraints on this element

Element id

Composition.custodian.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.custodian.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.custodian.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.custodian.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

Composition.custodian.identifier

Short description

Logical reference, when literal reference is not known

Definition

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

relatesTo

0..*

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship
cda: .relatedDocument
fhirdocumentreference: DocumentReference.relatesTo

0..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.relatesTo.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

code

1..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.relatesTo.code

Short description

replaces | transforms | signs | appends

Definition

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

Comments

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

Data type

DocumentRelationshipType (required)

Binding

The type of relationship between documents.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship.typeCode
cda: .relatedDocument.typeCode
fhirdocumentreference: DocumentReference.relatesTo.code

target[x]

1..1

There are no (further) constraints on this element

Element id

Composition.relatesTo.target[x]

Short description

Target of the relationship

Definition

The target composition/document of this relationship.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .target[classCode="DOC", moodCode="EVN"].id
cda: .relatedDocument.id
fhirdocumentreference: DocumentReference.relatesTo.target

targetIdentifier

There are no (further) constraints on this element

Data type

targetReference

There are no (further) constraints on this element

Data type

event

S Σ

0..*

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
cda: .documentationOf.serviceEvent
fhirdocumentreference: DocumentReference.event
CDR-data-in-v2: PV1.10

0..1

There are no (further) constraints on this element

Element id

Composition.event.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.event.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

code

0..*

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

Comments

Data type

Binding

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

v3.ActCode (example)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .code
cda: .code
fhirdocumentreference: DocumentReference.event.code

period

S Σ

1..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .effectiveTime
cda: .effectiveTime
fhirdocumentreference: DocumentReference.event.period

0..1

There are no (further) constraints on this element

Element id

Composition.event.period.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.period.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

start

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.event.period.start

Short description

Starting time with inclusive boundary

Definition

The start of the period. The boundary is inclusive.

Comments

If the low element is missing, the meaning is that the low boundary is not known.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: per-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: DR.1
rim: ./low

end

S Σ C

0..1

There are no (further) constraints on this element

Element id

Composition.event.period.end

Short description

End time with inclusive boundary, if not ongoing

Definition

Comments

The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.

Meaning when missing

If the end of the period is missing, it means that the period is ongoing

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: per-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: DR.2
rim: ./high

detail

S Σ

0..*

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship[typeCode="SUBJ"].target
cda: n/a

0..1

There are no (further) constraints on this element

Element id

Composition.event.detail.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.event.detail.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.event.detail.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.event.detail.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

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

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

section

S C

1..*

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

Constraints

cmp-1: A section must contain 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()
ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
cda: .component.structuredBody.component.section

1..1

Element id

Composition.section.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Comments

This is used to maintain the order of sections in the document. SMILE will generate this id that follows the order of OBX sequence (e.g. incremental, 1,2,3)

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Composition.section.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

title

0..1

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./title
cda: .title

code

0..1

Element id

Composition.section.code

Short description

Concept - reference to a terminology or just text

Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Requirements

Provides computable standardized labels to topics within the document.

Comments

For all CodeableConcepts, at least one of coding or text must be present. If coding contains only a display value (no code) then CodeableConcept must include text.

Data type

DocumentSectionCodes (example)

Binding

Classification of a section of a composition/document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: ./code
cda: .code
rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.code.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

coding

S Σ

1..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding

Short description

A reference to a code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

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

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.code.coding.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

system

S Σ

1..1

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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

S Σ

1..1

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.2 - but note this is not well followed
rim: CV.displayName
orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.id

Short description

xml:id (or equivalent in JSON)

Definition

unique id for the element within a resource (for internal references)

Data type

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

http://hl7.org/fhir/StructureDefinition/translation

Slicing

Unordered, Open, by url(Value)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

translation

S C

0..*

Extension(Complex)

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation

Short description

Language Translation (Localization)

Alternate names

extensions, user content

Definition

Language translation from base language of resource to another language.

Comments

Data type

Extension(Complex)

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: ST.translation

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

2..*

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

lang

1..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang

Short description

Code for Language

Definition

Code for Language.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

lang

Mappings

rim: N/A

value[x]

1..1

Binding

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:lang.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueCode

There are no (further) constraints on this element

Data type

content

1..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content

Short description

Content in other Language

Definition

Content in other Language.

Comments

The type (string or markdown) must match the context in which it is used.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

0..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..0

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content.extension

Short description

Extension

Definition

An Extension

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

content

Mappings

rim: N/A

value[x]

1..1

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.extension:content.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

valueString

There are no (further) constraints on this element

Data type

valueMarkdown

There are no (further) constraints on this element

Data type

url

1..1

uriFixed Value

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.url

Short description

identifies the meaning of the extension

Definition

Source of the definition for the extension code - a logical name or a URL.

Comments

Data type

Fixed value

http://hl7.org/fhir/StructureDefinition/translation

Mappings

rim: N/A

value[x]

0..0

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.extension:translation.value[x]

Short description

Value of extension

Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

value

0..1

System.String

There are no (further) constraints on this element

Element id

Composition.section.code.coding.display.value

Short description

Primitive value for string

Definition

The actual value

Data type

System.String

Maximum string length

1048576

userSelected

0..1

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 - e.g. 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

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

S Σ

0..1

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

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

author

0..*

There are no (further) constraints on this element

Element id

Composition.section.author

Short description

Who and/or what authored the section

Definition

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

Requirements

Identifies who is responsible for the content.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.author
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
cda: .author.assignedAuthor

focus

0..1

There are no (further) constraints on this element

Element id

Composition.section.focus

Short description

Who/what the section is about, when it is not about the subject of composition

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

cda: .subject? (CDA did not differentiate between subject and focus)

text

S C

0..1

There are no (further) constraints on this element

Element id

Composition.section.text

Short description

Text summary of the section, for human interpretation

Definition

Comments

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

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .text
cda: .text

mode

0..1

codeBinding

There are no (further) constraints on this element

Element id

Composition.section.mode

Short description

working | snapshot | changes

Definition

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 misunderstood as a complete list.

Data type

Binding

The processing mode that applies to this section.

ListMode (required)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.class
rim: .outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
cda: n/a

orderedBy

0..1

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

Data type

Binding

What order applies to the items in the entry.

ListOrderCodes (preferred)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship[typeCode=COMP].sequenceNumber > 1
cda: n/a

entry

S C

0..*

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

Conditions

The cardinality or value of this element may be affected by these constraints: cmp-2

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
cda: .entry

0..1

There are no (further) constraints on this element

Element id

Composition.section.entry.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Composition.section.entry.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

There are no (further) constraints on this element

Element id

Composition.section.entry.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

Composition.section.entry.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

Composition.section.entry.identifier

Short description

Logical reference, when literal reference is not known

Definition

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

There are no (further) constraints on this element

Element id

Composition.section.entry.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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

emptyReason

0..1

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

Data type