Important: This is a draft IG for trial use. Click here to give feedback.

Send ClinicalReportResearch

Introduction

This page describes the technical specification of the use case: Send ClinicalReportResearch.

Security considerations

This guide assumes that client and server are able to make a secure connection. It does not provide information on finding the right server nor does it provide information about security. Moreover, each transaction is performed in the context of a specific authenticated/authorized patient, for whose context (token) has been established using authentication mechanisms described elsewhere. Each actor is required to filter out all the records that are not associated with the authenticated patient.

Send ClinicalReportResearch by the Provider

The ClinicalReportResearch (CRR) is sent as a FHIR Document. A document is a FHIR Bundle that assembles all relevant resources that need to be exchanged, together with a Composition resource that summarizes and references all these resources. This allows to include referenced secondary resources too. The interaction is performed by an HTTP POST command as shown:

POST [fhir base url]/Bundle

The body of the POST submission is a Bundle that has Bundle.type = document and contains a globally unique Bundle.identifier for this instance of the CRR message and is never re-used. The first Bundle.entry is the ClinicalReportResearch-Composition. At least the Patient and one or more clincal related resources are expected to be included as well.

The Provider SHALL guarantee consistency of all FHIR resource elements with the requirements specified in the FHIR-profiles referenced from the Composition profile or from the referenced profiles. This page provides an overview of FHIR profiles in the CRR and links to the profile pages in the CBB implementation guide.

Composition

The Composition is structured using sections, each with its own fixed code (.section.code) that is added to the Composition resource instance. The sections and codes are aligned with sections in the International Patient Summary (IPS). The administrativeData and encounter sections do not exist in the IPS and are coded separately.


identifierΣ0..1Identifier
statusΣ ?!1..1codeBinding
typeΣ1..1CodeableConceptBinding
categoryΣ0..*CodeableConcept
subjectΣ I1..1Reference(Patient | HdBe Patient)
encounterΣ I0..1Reference(Encounter)
dateΣ1..1dateTime
authorΣ I1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization Organization)
titleΣ1..1string
confidentialityΣ0..1codeBinding
mode1..1codeBinding
time0..1dateTime
partyI0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
custodianΣ I0..1Reference(Organization | HdBe HealthcareOrganization Organization)
code1..1codeBinding
targetIdentifierIdentifier
targetReferenceReference(Composition | HdBe ClinicalReport for Research Composition)
codeΣ0..*CodeableConcept
periodΣ I0..1Period
detailΣ I0..*Reference(Resource)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(Resource)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe ContactPerson | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization | HdBe HealthcareOrganization Organization)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe MedicationAdministration2 | HdBe MedicationAgreement | HdBe MedicationUse2)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe AllergyIntolerance)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe Problem)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe Procedure event | HdBe Procedure request)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe Vaccination event)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe MedicalDevice | HdBe MedicalDevice.Product)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe BloodPressure | HdBe BodyHeight | HdBe BodyTemperature | HdBe BodyWeight)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe FunctionalOrMentalStatus | HdBe HearingFunction | HdBe HearingFunction.HearingAid | HdBe HearingFunction.HearingAid.Product | HdBe VisualFunction.VisualAid.Product | HdBe VisualFunction.VisualAid | HdBe VisualFunction)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe SmokingStatus)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe Encounter)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)

identifierΣ0..1Identifier
statusΣ ?!1..1codeBinding
typeΣ1..1CodeableConceptBinding
categoryΣ0..*CodeableConcept
subjectΣ I1..1Reference(Patient | HdBe Patient)
encounterΣ I0..1Reference(Encounter)
dateΣ1..1dateTime
authorΣ I1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization Organization)
titleΣ1..1string
confidentialityΣ0..1codeBinding
mode1..1codeBinding
time0..1dateTime
partyI0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
custodianΣ I0..1Reference(Organization | HdBe HealthcareOrganization Organization)
code1..1codeBinding
targetIdentifierIdentifier
targetReferenceReference(Composition | HdBe ClinicalReport for Research Composition)
codeΣ0..*CodeableConcept
periodΣ I0..1Period
detailΣ I0..*Reference(Resource)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(Resource)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe ContactPerson | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization | HdBe HealthcareOrganization Organization)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe MedicationAdministration2 | HdBe MedicationAgreement | HdBe MedicationUse2)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe AllergyIntolerance)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe Problem)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe Procedure event | HdBe Procedure request)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe Vaccination event)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe MedicalDevice | HdBe MedicalDevice.Product)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe BloodPressure | HdBe BodyHeight | HdBe BodyTemperature | HdBe BodyWeight)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe FunctionalOrMentalStatus | HdBe HearingFunction | HdBe HearingFunction.HearingAid | HdBe HearingFunction.HearingAid.Product | HdBe VisualFunction.VisualAid.Product | HdBe VisualFunction.VisualAid | HdBe VisualFunction)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe SmokingStatus)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe Encounter)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)

identifierΣ0..1Identifier
statusΣ ?!1..1codeBinding
typeΣ1..1CodeableConceptBinding
categoryΣ0..*CodeableConcept
subjectΣ I1..1Reference(Patient | HdBe Patient)
encounterΣ I0..1Reference(Encounter)
dateΣ1..1dateTime
authorΣ I1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization Organization)
titleΣ1..1string
confidentialityΣ0..1codeBinding
mode1..1codeBinding
time0..1dateTime
partyI0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
custodianΣ I0..1Reference(Organization | HdBe HealthcareOrganization Organization)
code1..1codeBinding
targetIdentifierIdentifier
targetReferenceReference(Composition | HdBe ClinicalReport for Research Composition)
codeΣ0..*CodeableConcept
periodΣ I0..1Period
detailΣ I0..*Reference(Resource)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(Resource)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe ContactPerson | HdBe HealthProfessional Practitioner | HdBe HealthProfessional PractitionerRole | HdBe HealthcareOrganization | HdBe HealthcareOrganization Organization)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe MedicationAdministration2 | HdBe MedicationAgreement | HdBe MedicationUse2)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe AllergyIntolerance)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe Problem)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe Procedure event | HdBe Procedure request)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe Vaccination event)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe MedicalDevice | HdBe MedicalDevice.Product)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe BloodPressure | HdBe BodyHeight | HdBe BodyTemperature | HdBe BodyWeight)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe FunctionalOrMentalStatus | HdBe HearingFunction | HdBe HearingFunction.HearingAid | HdBe HearingFunction.HearingAid.Product | HdBe VisualFunction.VisualAid.Product | HdBe VisualFunction.VisualAid | HdBe VisualFunction)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe SmokingStatus)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)
title0..1string
code1..1CodeableConcept
authorI0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)
focusI0..1Reference(Resource)
textI0..1Narrative
mode0..1codeBinding
orderedBy0..1CodeableConceptBinding
entryI0..*Reference(HdBe Encounter)
emptyReasonI0..1CodeableConceptBinding
sectionI0..*see (section)

SectionCodeSystemCodeValue
administrativeDatahttp://snomed.info/sct405624007
medicationhttp://loinc.org10160-0
allergieshttp://loinc.org48765-2
problemshttp://loinc.org11450-4
procedureshttp://loinc.org47519-4
immunizationshttp://loinc.org11369-6
medicalDeviceshttp://loinc.org46264-8
vitalSignshttp://loinc.org8716-3
functionalStatushttp://loinc.org47420-5
socialHistoryhttp://loinc.org29762-2
encountershttp://snomed.info/sct371531000

SectionProfiles
administrativeDatahttps://fhir.healthdata.be/StructureDefinition/HdBe-ContactPerson; https://fhir.healthdata.be/StructureDefinition/HdBe-HealthProfessional-Practitioner; https://fhir.healthdata.be/StructureDefinition/HdBe-HealthProfessional-PractitionerRole; https://fhir.healthdata.be/StructureDefinition/HdBe-HealthcareOrganization; https://fhir.healthdata.be/StructureDefinition/HdBe-HealthcareOrganization-Organization
medicationhttps://fhir.healthdata.be/StructureDefinition/HdBe-MedicationAdministration2; https://fhir.healthdata.be/StructureDefinition/HdBe-MedicationAgreement; https://fhir.healthdata.be/StructureDefinition/HdBe-MedicationUse2
allergieshttps://fhir.healthdata.be/StructureDefinition/HdBe-AllergyIntolerance
problemshttps://fhir.healthdata.be/StructureDefinition/HdBe-Problem
procedureshttps://fhir.healthdata.be/StructureDefinition/HdBe-Procedure-event; https://fhir.healthdata.be/StructureDefinition/HdBe-Procedure-request
immunizationshttps://fhir.healthdata.be/StructureDefinition/HdBe-Vaccination-event
medicalDeviceshttps://fhir.healthdata.be/StructureDefinition/HdBe-MedicalDevice; https://fhir.healthdata.be/StructureDefinition/HdBe-MedicalDevice.Product
vitalSignshttps://fhir.healthdata.be/StructureDefinition/HdBe-BloodPressure; https://fhir.healthdata.be/StructureDefinition/HdBe-BodyHeight; https://fhir.healthdata.be/StructureDefinition/HdBe-BodyTemperature; https://fhir.healthdata.be/StructureDefinition/HdBe-BodyWeight
functionalStatushttps://fhir.healthdata.be/StructureDefinition/HdBe-FunctionalOrMentalStatus; https://fhir.healthdata.be/StructureDefinition/HdBe-HearingFunction; https://fhir.healthdata.be/StructureDefinition/HdBe-HearingFunction.HearingAid; https://fhir.healthdata.be/StructureDefinition/HdBe-HearingFunction.HearingAid.Product; https://fhir.healthdata.be/StructureDefinition/HdBe-VisualFunction.VisualAid.Product; https://fhir.healthdata.be/StructureDefinition/HdBe-VisualFunction.VisualAid; https://fhir.healthdata.be/StructureDefinition/HdBe-VisualFunction
socialHistoryhttps://fhir.healthdata.be/StructureDefinition/HdBe-SmokingStatus
encountershttps://fhir.healthdata.be/StructureDefinition/HdBe-Encounter

Resource references

The Provider system SHALL produce a complete Bundle containing not only the resources listed directly in the Composition, but all the indirectly referenced resources (such as PharmaceuticalProduct referenced by MedicationAgreement) as well. This should prevent the receiving system to resolve references at the sending system. The CBB implementation guide provides additional guidance on the use of the reference data type.

Identification

Resources SHALL have a stable identifier in the .identifier element for all resources if such an identifier exists in the underlying data. Not all data, like individual results, are currently known to have identifiers in all source systems, but when they exist they are essential and where they do not exist yet they SHOULD be considered. Having stable identification is essential in detection of duplicates. For more information on dealing with identifiers, see the CBB implementation guide.

Examples

Receive ClinicalReportResearch by the Consumer

The document Bundle should be processed as a transaction by the Consumer. The Consumer response shall be sent when a success or error condition needs to be communicated. Success is only indicated once the Bundle and accompanying resources are received and completely processed and persisted as appropriate to the Consumer configuration. The Consumer returns an HTTP Status code appropriate to the processing outcome.

Usage in DCDs

Generally, DCDs require parts of a CRR. Moreover, they can also require additional data elements. This is supported by this Composition profile, based on the following defined implementation rules:

  • A derived ClinicalReportResearch-Composition profile is created that specifies the information requirements.
  • The title of the Composition SHALL match the name of the DCD.
  • Additional sections are added for each segment of a DCD that is missing in the CRR, designated with a meaningful code in .section.code.