CambioOpenServicesIG - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

• Content
• Detailed Descriptions
• JSON

Resource Profile: CompositionReferralClinicalInformation

Introduction

The CompositionReferralClinicalInformation profile defines clinical information structured on sections with titles and values which can be sent together with a referral request, answer or assessment. E.g. the documentation done when sending a referral can include data like medical history, health issue, etc. This profile is based on the FHIR resource Composition.

Intended Use

Intended use of this profile is to communicate data about a documented clinical information that is connected to a referral request, assessment or answer. The user of the API should be restricted only to the patient to which the data belongs. CompositionReferralClinicalInformation can only be used as a bundled resource within the TaskReferral and ServiceRequestReferral APIs, refer to TaskReferral and ServiceRequestReferral sections to read more about complete Intended use for the API.

Additionally, CompositionReferralClinicalInformation includes the extension common-signDateTime to indicate the date & time the data was signed.

Specific Rules and Limitations

Versions

Usages:

• Refer to this Profile: ServiceRequestReferral and TaskReferral

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	This composition represents Clinical information structured on sections with titles an values.
meta	Σ	1..1	Meta	Metadata about the resource
profile	Σ	1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:signDateTime		0..*	dateTime	Extension URL: https://fhir.cambio.se/StructureDefinition/common-signDateTime
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	preliminary | final | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	Σ	1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: Referral Documentation Types (required)
Slices for category	Σ	0..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:referralNoteLoinc	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:referralNoteSnomed	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
date	Σ	1..1	dateTime	Composition editing time
Slices for author	Σ	1..*	Reference(PractitionerRoleLiteSe | Organization | Practitioner | Patient)	Who and/or what authored the composition Slice: Unordered, Open by value:type
author:All Slices				Content/Rules for all slices
type	Σ	1..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
author:patient	Σ	0..*	Reference(Patient)	Who and/or what authored the composition
type	Σ	1..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Fixed Value: Patient
title	Σ	1..1	string	Human Readable name/title
attester		0..1	BackboneElement	Attests to accuracy of composition
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional
party		1..1	Reference(PractitionerRoleLiteSe | Practitioner)	Who attested the composition
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 From the FHIR Standard
Composition.type	required	ReferralDocumentationTypes https://cambio.codes/referral-documentation-type/v1 From this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.category:referralNoteLoinc	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.category:referralNoteSnomed	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.author.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
Composition.author:patient.type	extensible	Fixed Value: Patient http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
Composition.attester.mode	required	Fixed Value: professional http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	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	error	Composition	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	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from Composition

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	This composition represents Clinical information structured on sections with titles an values.
meta		1..1	Meta	Metadata about the resource
profile		1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:signDateTime		0..*	dateTime	Extension URL: https://fhir.cambio.se/StructureDefinition/common-signDateTime
identifier		0..0
status		1..1	code	preliminary | final | entered-in-error
type		1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: Referral Documentation Types (required)
Slices for category		0..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system
category:referralNoteLoinc		0..*	CodeableConcept	Categorization of Composition
coding
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		0..1	code	Symbol in syntax defined by the system Fixed Value: 57133-1
category:referralNoteSnomed		0..*	CodeableConcept	Categorization of Composition
coding
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		0..1	code	Symbol in syntax defined by the system Fixed Value: 721927009
subject		0..0
encounter		0..0
Slices for author		1..*	Reference(PractitionerRoleLiteSe | Organization | Practitioner | Patient)	Who and/or what authored the composition Slice: Unordered, Open by value:type
author:All Slices				Content/Rules for all slices
type		1..1	uri	Type the reference refers to (e.g. "Patient")
author:patient		0..*	Reference(Patient)	Who and/or what authored the composition
type		1..1	uri	Type the reference refers to (e.g. "Patient") Fixed Value: Patient
title		1..1	string	Human Readable name/title
attester		0..1	BackboneElement	Attests to accuracy of composition
mode		1..1	code	personal | professional | legal | official Fixed Value: professional
party		1..1	Reference(PractitionerRoleLiteSe | Practitioner)	Who attested the composition
custodian		0..0
relatesTo		0..0
event		0..0
section
title		1..1	string	Name of component
code		0..0
author		0..0
focus		0..0
text		0..0
mode		0..0
orderedBy		0..0
entry
display		1..1	string	Text alternative for the resource
emptyReason		0..0
section		0..0
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.type	required	ReferralDocumentationTypes https://cambio.codes/referral-documentation-type/v1 From this IG

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	This composition represents Clinical information structured on sections with titles an values.
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	1..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	Σ	0..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	Σ	1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:signDateTime		0..*	dateTime	Extension URL: https://fhir.cambio.se/StructureDefinition/common-signDateTime
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	preliminary | final | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	Σ	1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: Referral Documentation Types (required)
Slices for category	Σ	0..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:referralNoteLoinc	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system Fixed Value: 57133-1
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category:referralNoteSnomed	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system Fixed Value: 721927009
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
date	Σ	1..1	dateTime	Composition editing time
Slices for author	Σ	1..*	Reference(PractitionerRoleLiteSe | Organization | Practitioner | Patient)	Who and/or what authored the composition Slice: Unordered, Open by value:type
author:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	1..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
author:patient	Σ	0..*	Reference(Patient)	Who and/or what authored the composition
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	1..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Fixed Value: Patient
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
title	Σ	1..1	string	Human Readable name/title
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
attester		0..1	BackboneElement	Attests to accuracy of composition
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional
time		0..1	dateTime	When the composition was attested
party		1..1	Reference(PractitionerRoleLiteSe | Practitioner)	Who attested the composition
section	C	0..*	BackboneElement	Composition is broken into sections Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		1..1	string	Name of component
entry	C	0..*	Reference(Resource)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	1..1	string	Text alternative for the resource
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.meta.security	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels From the FHIR Standard
Composition.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags From the FHIR Standard
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 From the FHIR Standard
Composition.type	required	ReferralDocumentationTypes https://cambio.codes/referral-documentation-type/v1 From this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.category:referralNoteLoinc	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.category:referralNoteSnomed	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.author.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
Composition.author:patient.type	extensible	Fixed Value: Patient http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 From the FHIR Standard
Composition.attester.mode	required	Fixed Value: professional http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From the FHIR Standard
Composition.event.code	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.text.status	required	Fixed Value: additional http://hl7.org/fhir/ValueSet/narrative-status|4.0.1 From the FHIR Standard
Composition.section.entry.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section	A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section	A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	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	error	Composition	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	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
txt-1	error	Composition.section.text.div	The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes : htmlChecks()
txt-2	error	Composition.section.text.div	The narrative SHALL have some non-whitespace content : htmlChecks()

This structure is derived from Composition

Summary

Mandatory: 3 elements(5 nested mandatory elements)
Fixed: 7 elements
Prohibited: 14 elements

Structures

This structure refers to these other structures:

• PractitionerRoleLiteSe (https://fhir.cambio.se/StructureDefinition/PractitionerRoleLiteSe/v1)

Extensions

This structure refers to these extensions:

• https://fhir.cambio.se/StructureDefinition/common-signDateTime

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Composition.category
• The element 1 is sliced based on the value of Composition.author

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	This composition represents Clinical information structured on sections with titles an values.
meta	Σ	1..1	Meta	Metadata about the resource
profile	Σ	1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:signDateTime		0..*	dateTime	Extension URL: https://fhir.cambio.se/StructureDefinition/common-signDateTime
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	preliminary | final | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	Σ	1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: Referral Documentation Types (required)
Slices for category	Σ	0..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:referralNoteLoinc	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:referralNoteSnomed	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
date	Σ	1..1	dateTime	Composition editing time
Slices for author	Σ	1..*	Reference(PractitionerRoleLiteSe | Organization | Practitioner | Patient)	Who and/or what authored the composition Slice: Unordered, Open by value:type
author:All Slices				Content/Rules for all slices
type	Σ	1..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
author:patient	Σ	0..*	Reference(Patient)	Who and/or what authored the composition
type	Σ	1..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Fixed Value: Patient
title	Σ	1..1	string	Human Readable name/title
attester		0..1	BackboneElement	Attests to accuracy of composition
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional
party		1..1	Reference(PractitionerRoleLiteSe | Practitioner)	Who attested the composition
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 From the FHIR Standard
Composition.type	required	ReferralDocumentationTypes https://cambio.codes/referral-documentation-type/v1 From this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.category:referralNoteLoinc	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.category:referralNoteSnomed	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.author.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
Composition.author:patient.type	extensible	Fixed Value: Patient http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
Composition.attester.mode	required	Fixed Value: professional http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	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	error	Composition	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	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Differential View

This structure is derived from Composition

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	This composition represents Clinical information structured on sections with titles an values.
meta		1..1	Meta	Metadata about the resource
profile		1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:signDateTime		0..*	dateTime	Extension URL: https://fhir.cambio.se/StructureDefinition/common-signDateTime
identifier		0..0
status		1..1	code	preliminary | final | entered-in-error
type		1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: Referral Documentation Types (required)
Slices for category		0..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system
category:referralNoteLoinc		0..*	CodeableConcept	Categorization of Composition
coding
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		0..1	code	Symbol in syntax defined by the system Fixed Value: 57133-1
category:referralNoteSnomed		0..*	CodeableConcept	Categorization of Composition
coding
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		0..1	code	Symbol in syntax defined by the system Fixed Value: 721927009
subject		0..0
encounter		0..0
Slices for author		1..*	Reference(PractitionerRoleLiteSe | Organization | Practitioner | Patient)	Who and/or what authored the composition Slice: Unordered, Open by value:type
author:All Slices				Content/Rules for all slices
type		1..1	uri	Type the reference refers to (e.g. "Patient")
author:patient		0..*	Reference(Patient)	Who and/or what authored the composition
type		1..1	uri	Type the reference refers to (e.g. "Patient") Fixed Value: Patient
title		1..1	string	Human Readable name/title
attester		0..1	BackboneElement	Attests to accuracy of composition
mode		1..1	code	personal | professional | legal | official Fixed Value: professional
party		1..1	Reference(PractitionerRoleLiteSe | Practitioner)	Who attested the composition
custodian		0..0
relatesTo		0..0
event		0..0
section
title		1..1	string	Name of component
code		0..0
author		0..0
focus		0..0
text		0..0
mode		0..0
orderedBy		0..0
entry
display		1..1	string	Text alternative for the resource
emptyReason		0..0
section		0..0
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.type	required	ReferralDocumentationTypes https://cambio.codes/referral-documentation-type/v1 From this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	This composition represents Clinical information structured on sections with titles an values.
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	1..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	Σ	0..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	Σ	1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:signDateTime		0..*	dateTime	Extension URL: https://fhir.cambio.se/StructureDefinition/common-signDateTime
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	preliminary | final | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	Σ	1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: Referral Documentation Types (required)
Slices for category	Σ	0..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:referralNoteLoinc	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system Fixed Value: 57133-1
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category:referralNoteSnomed	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system Fixed Value: 721927009
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
date	Σ	1..1	dateTime	Composition editing time
Slices for author	Σ	1..*	Reference(PractitionerRoleLiteSe | Organization | Practitioner | Patient)	Who and/or what authored the composition Slice: Unordered, Open by value:type
author:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	1..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
author:patient	Σ	0..*	Reference(Patient)	Who and/or what authored the composition
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	1..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Fixed Value: Patient
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
title	Σ	1..1	string	Human Readable name/title
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
attester		0..1	BackboneElement	Attests to accuracy of composition
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. Fixed Value: professional
time		0..1	dateTime	When the composition was attested
party		1..1	Reference(PractitionerRoleLiteSe | Practitioner)	Who attested the composition
section	C	0..*	BackboneElement	Composition is broken into sections Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		1..1	string	Name of component
entry	C	0..*	Reference(Resource)	A reference to data that supports this section
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	1..1	string	Text alternative for the resource
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Composition.meta.security	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels From the FHIR Standard
Composition.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags From the FHIR Standard
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 From the FHIR Standard
Composition.type	required	ReferralDocumentationTypes https://cambio.codes/referral-documentation-type/v1 From this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.category:referralNoteLoinc	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.category:referralNoteSnomed	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
Composition.author.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
Composition.author:patient.type	extensible	Fixed Value: Patient http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 From the FHIR Standard
Composition.attester.mode	required	Fixed Value: professional http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 From the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From the FHIR Standard
Composition.event.code	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
Composition.section.text.status	required	Fixed Value: additional http://hl7.org/fhir/ValueSet/narrative-status|4.0.1 From the FHIR Standard
Composition.section.entry.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section	A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section	A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	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	error	Composition	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	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
txt-1	error	Composition.section.text.div	The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes : htmlChecks()
txt-2	error	Composition.section.text.div	The narrative SHALL have some non-whitespace content : htmlChecks()

This structure is derived from Composition

Summary

Mandatory: 3 elements(5 nested mandatory elements)
Fixed: 7 elements
Prohibited: 14 elements

Structures

This structure refers to these other structures:

• PractitionerRoleLiteSe (https://fhir.cambio.se/StructureDefinition/PractitionerRoleLiteSe/v1)

Extensions

This structure refers to these extensions:

• https://fhir.cambio.se/StructureDefinition/common-signDateTime

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Composition.category
• The element 1 is sliced based on the value of Composition.author

Other representations of profile: CSV, Excel, Schematron